CPT CODE 38220, 38221, G0364 - Bone Marrow

CPT code and description

38220 - Bone marrow; aspiration only - Average fee amount - $150 - $200

38221 - Bone marrow; biopsy, needle or trocar - Average fee amount - $150 - $200

G0364  Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service

DESCRIPTION

Bone marrow aspiration and bone marrow biopsy procedures are often performed together, often at the same surgical site. If aspiration is performed alone, the appropriate code to report is CPT code 38220. When a bone marrow biopsy is performed alone, the appropriate code to report is CPT code 38221.

CPT codes 38220 and 38221 may only be reported together if the two procedures are performed at separate and distinct sites, or at separate patient encounters. Separate sites include bone marrow aspiration and biopsy in different bones or with two separate skin incisions over the same bone.

For sequenced procedures, a bone marrow biopsy (38221) and bone marrow aspiration (38220), are performed through the same incision on the same date of service, HCPCS code G0364 should be used. In this case, CPT code 38221 should be reported for the biopsy, and HCPCS code G0364 should be reported for the aspiration. If documentation supports the same surgical site, the provider must report procedure codes 38221 and G0364. No payment will be made for HCPCS code G0364 when reported independently.


Physician hematology services include microscopic evaluation of bone marrow aspirations and biopsies. It also includes those limited number of peripheral blood smears which need to be referred to a physician to evaluate the nature of an apparent abnormality identified by the technologist. These codes include 85060, 38220, 85097, and 38221

For the other listed hematology codes, payment may be made for the professional component if the service is furnished to a patient by a hospital physician or independent laboratory. In addition, payment may be made for these services furnished to patients by an independent laboratory

Codes 38220 and 85097 represent professional-only component services and have no technical component values.



Physician hematology services include microscopic evaluation of bone marrow aspirations and biopsies. It also includes those limited number of peripheral blood smears which need to be referred to a physician to evaluate the nature of an apparent abnormality identified by the technologist. These codes include 85060, 38220, 85097, and 38221.

CODING/BILLING INFORMATION

The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.

HCPCS CODE

G0364 Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service

ICD-9-CM CODES

 8220 Bone marrow; aspiration only

38221 Bone marrow; biopsy, needle or trocar


POLICY

Reimbursement for bone marrow aspiration and bone marrow biopsy procedures for all product lines:

** 38221 with G0364 allows separate reimbursement

** G0364 will deny when billed independently

** G0364 will deny when billed with procedure 38220

** 38220 will deny when billed with procedure 38221

** 38220-59 with 38221 will allow separate reimbursement when documentation review supports separate sites


BCBS Payment policy


CODE           RULE           CODE

38221 Separate Reimbursement G0364

38220 Incidental 38221

38220-59 Separate Reimbursement 38221


This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

38220 in combination with 22510, 22511, 22512, 22513, 22514, 22515, 22533, 22534, 22548, 22551, 22552, 22554, 22558, 22585, 22586, 22590, 22595, 22600, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22856, 22857, 22861, 22864, 22865, 27279, 27280, 27299, 27702, 27703

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.



Bone Marrow or Stem Cell Services/Procedures - Codes 38204, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214 and 38215 are considered incidental to 38240, 38241 and 38242. Separate reimbursement is not allowed for incidental services.


HMO, PPO, Individual Marketplace, Elite, Advantage

Procedure G0364 was created to report a bone marrow aspiration performed on the same date through the same incision as a bone marrow biopsy. Procedure G0364 is to be reported with the bone marrow biopsy code, procedure 38221. If the biopsy and aspiration are performed through different incisions or different patient encounters on the same day, then the procedure should be reported with procedure 38220-59 and 38221.

Paramount bundles procedures 38220 as incidental when billed with procedure 38221. If on appeal the documentation supports that procedure 38220 was performed at one anatomical site and procedure 38221 is performed at a different anatomical site or through a separate incision from procedure 38220 then separate reimbursement will be warranted. Procedure codes 38220 and 38221 may only be reported together if the two procedures are performed at separate sites or at separate patient encounters. When both the bone marrow biopsy (CPT code 38221) and bone marrow aspiration (CPT code 38220) are performed at the same site through the same skin incision, do not report the bone marrow aspiration (CPT code 38220) in addition to the bone marrow biopsy (CPT code 38221). HCPCS/CPT codes G0364 and 38221 may be reported to describe the bone marrow aspiration performed with bone marrow biopsy through the same skin incision on the same date of service


Rationale Edit

Anthem Central Region does not bundle 38221 with G0364. Based on the Federal Register, it states: “In the August 5, 2004 rule, we proposed a new add-on G-code, G0364 (proposed as G0ZZ1); Bone marrow biopsy through same incision on same date of service. The physician would use the CPT code for marrow biopsy (38221) and G0364 for the second procedure (bone marrow aspiration).” Based on the National Correct Coding Initiative Edits, code 38221 is not listed as a component code to code G0364. Therefore, if 38221 is submitted with G0364—both reimburse separately.

Anthem Central Region bundles 38220 as incidental with 38221. Based on the National Correct Coding Initiative edits, code 38221 is listed as a component code to code 38220. Therefore, if 38220 is submitted with 38221—only 38221 reimburses.

Anthem Central Region does not bundle 38220-59 with 38221. Based on the Federal Register, it states:

“In the August 5, 2004 proposed rule, we also stated that if the two procedures, aspiration and biopsy, are performed at different sites {for example, contralateral iliac crests, sternum/iliac crest or two separate incision on the same iliac crest}, the -59 modifier, which denotes a distinct procedure service, is appropriate to use and Medicare’s multiple procedure rule will apply, in this instance, the CPT codes for aspiration and biopsy are each being used). Therefore, if 38220-59 is submitted with 38221—both reimburse separately.

If on complaint, it is documented that 38220 was performed at one anatomical site and 38221 is performed at a different anatomical site or through a separate incision from 38220—both reimburse separately

If the same procedure is performed at different anatomic sites, it does not necessarily imply that a HCPCS/CPT code may be reported with more than one unit of service (UOS) for the procedure. Determining whether additional UOS may be reported depends upon the HCPCS/CPT code descriptor and the code’s UOS.



Example: The column one/column two code edit with column one CPT code 38221 (bone marrow biopsy) and column two CPT code 38220(bone marrow, aspiration only) includes two distinct procedures when performed at separate anatomic sites or separate patient encounters. In these circumstances, it would be acceptable to use modifier 59. However, if both 38221 and 38220
are performed through the same skin incision at the same patient encounter which is the usual practice, modifier 59 should NOT be used. Although CMS does not allow separate payment for CPT code 38220 with CPT code 38221 when bone marrow aspiration and biopsy are performed through the same skin incision at a single patient encounter, CMS does allow separate payment for HCPCS level II code G0364 (bone marrow aspiration performed with bone marrow biopsy through same incision on the same date of service) with CPT code 38221 under these circumstances.


Other codes.

When a patient has a lesion or disease of the bone, rather than of the bone marrow, a biopsy specimen of the bone is taken to establish the diagnosis. In general, the clinical presentation will be a patient with a specific lesion of bone seen by x-ray or imaging studies. This may be a primary bone tumor, a metastasis, or may represent a metabolic derangement of bone, such as seen in Paget’s disease or in the brown tumor of hyperparathyroidism. For example, a lytic lesion of bone may be biopsied to establish the nature of the underlying process, whether malignant or metabolic.

The procedure involves the removal of bone, including one or both cortical plates, and of representative material of the cancellous bone, if appropriate. Since the purpose of the biopsy is to establish a diagnosis for a bone lesion, the presence of bone marrow in the biopsy specimen is only incidental.

In certain situations, percutaneous needle biopsy (of bone) allows for histologic diagnosis with lower cost and morbidity than open biopsy does. This is particularly true for tumors of the spinal column. A percutaneous needle biopsy can allow metastasis to be excluded or confirmed. If surgical intervention is contemplated, a needle is rarely performed. Codes 20220, 20225 describe the removal of a specimen of bone (not of bone marrow) by using a trocar or needle.

If a primary bone tumor is suspected, an open biopsy, rather than a needle biopsy, is generally performed.

Codes 20240 20240 20245 20250 - 20251 describe open bone biopsies.

A surgical incision is made as directly as possible down to the bone lesion. The surgeon generally goes through muscle rather than dissecting around muscle planes, in order to minimize dissemination of the lesion. Care is also taken to provide the excellent hemostasis to minimize the dissemination of tumor cells around the biopsy site.

In Summary

1. CPT code 85102 describes a biopsy of the bone marrow using a needle or trocar when a core of bone marrow is withdrawn with the needle.
2. CPT code 85095 describes an aspiration of the bone marrow when tissue is aspirated from the bone marrow into a needle attached to a syringe.
3. CPT codes 20220, 20225 describe the removal of a portion of bone (not bone marrow) via a needle or trocar.
4. CPT code 88305 describes the examination of the bone marrow cell block prepared from the smear.
5. CPT code 88305 describes the examination of the bone marrow biopsy.
6. CPT code 88307 describes the examination of the bone biopsy.
7. CPT code 88311 describes the decalcification of bone marrow biopsy or bone biopsy.
8. CPT codes 20240 20240 20245 20250 - 20251 describe bone (not bone marrow) biopsies performed through an open incision.
9. CPT code 85097 describes the examination of the bone marrow smear. Other CPT codes may be reported as needed to establish the diagnosis (eg, special or immunohistochemical techniques).





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