38222

Bone marrow biopsy, needle or trocar

A bone marrow biopsy, identified by CPT code 38222, is a critical diagnostic procedure involving the extraction of a solid core sample of bone marrow for microscopic examination. This procedure is distinct from a bone marrow aspiration (38220), which obtains a liquid sample, though both are frequently performed concurrently from the same site. The biopsy provides essential information regarding the architectural structure of the bone marrow, cellularity, stromal elements, and the presence of infiltrative diseases, fibrosis, or granulomas, which may not be fully appreciated in an aspirate. The procedure is typically performed in an outpatient setting, often at the posterior superior iliac spine (PSIS) of the pelvis in adults, or less commonly at other sites like the sternum. After local anesthesia and sterile preparation of the chosen site, a specialized bone marrow biopsy needle, such as a Jamshidi needle, is carefully advanced through the skin, subcutaneous tissue, and cortical bone into the marrow cavity. Once inside, the needle is rotated to cut and secure a small cylindrical core of marrow tissue, typically 1 to 2 centimeters in length. The needle is then withdrawn, and the core sample is carefully expelled into a fixative solution for pathological processing, which includes decalcification, embedding, sectioning, and staining. This allows for detailed histopathological analysis to diagnose, stage, and monitor a wide array of hematologic disorders, malignancies, and other systemic diseases affecting the bone marrow. The biopsy is pivotal in guiding treatment strategies and assessing prognosis for conditions ranging from leukemia and lymphoma to unexplained anemias and infections.

Clinical Indications

  • Diagnosis and staging of acute and chronic leukemias (e.g., AML, ALL, CML, CLL)
  • Diagnosis and staging of lymphomas (e.g., Hodgkin's lymphoma, non-Hodgkin's lymphoma)
  • Diagnosis and assessment of plasma cell disorders (e.g., multiple myeloma, amyloidosis)
  • Evaluation of myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN) (e.g., polycythemia vera, essential thrombocythemia, myelofibrosis)
  • Investigation of unexplained cytopenias (anemia, leukopenia, thrombocytopenia) or pancytopenia
  • Evaluation of unexplained elevated blood counts (e.g., erythrocytosis, thrombocytosis, leukocytosis)
  • Diagnosis of aplastic anemia and other bone marrow failure syndromes
  • Detection of metastatic cancer cells in the bone marrow from solid tumors (e.g., breast, lung, prostate cancer)
  • Diagnosis of granulomatous diseases (e.g., tuberculosis, sarcoidosis) or fungal infections affecting the bone marrow
  • Evaluation of fever of unknown origin (FUO) when bone marrow pathology is suspected
  • Assessment of bone marrow iron stores in cases of suspected iron overload or unexplained iron deficiency
  • Monitoring response to treatment for various hematologic malignancies and disorders
  • Diagnosis of storage diseases affecting the bone marrow
  • Investigation of unexplained hepatomegaly or splenomegaly

Procedure Steps

  1. Patient positioning (typically prone or lateral decubitus for posterior iliac crest).
  2. Sterile preparation of the biopsy site (e.g., posterior superior iliac spine) using antiseptic solution and sterile drapes.
  3. Local anesthesia infiltration (e.g., lidocaine) into the skin, subcutaneous tissue, periosteum, and bone to minimize pain.
  4. Optional small skin incision to facilitate needle insertion.
  5. Insertion of a specialized bone marrow biopsy needle (e.g., Jamshidi) with stylet through the skin and cortical bone into the marrow cavity.
  6. Removal of the stylet once the needle is firmly seated in the marrow.
  7. Advancement of the biopsy needle 1-2 cm further into the marrow cavity with gentle rotation to obtain a core sample.
  8. Withdrawal of the needle with the bone marrow core sample.
  9. Careful expulsion of the bone marrow core into a fixative solution (e.g., formalin) for pathological processing.
  10. Application of pressure to the biopsy site to achieve hemostasis, followed by a sterile dressing.

Coding Guidelines

  • CPT code 38222 specifically describes the bone marrow biopsy, which obtains a core sample of marrow tissue.
  • If both a bone marrow aspiration (38220) and a bone marrow biopsy (38222) are performed during the same encounter, both codes may be reported, as they represent distinct procedural services.
  • When reporting both 38220 and 38222, it is common to use modifier -59 (Distinct Procedural Service) or an XU modifier on 38220 if it is performed through a separate skin incision or at a different site than the biopsy, or if it represents a distinct and independent procedure.
  • CPT 38222 is a unilateral procedure. If bilateral bone marrow biopsies are performed (e.g., from both posterior iliac crests), report 38222 with modifier -50 (Bilateral procedure) or report 38222 twice with a -59 modifier and units of 2, depending on payer guidelines.
  • The professional interpretation of the bone marrow biopsy specimen by a pathologist is reported separately using surgical pathology codes (e.g., 88305, 88307, 88309).
  • Imaging guidance (e.g., fluoroscopy, CT, ultrasound) used during the bone marrow biopsy should be reported separately with the appropriate imaging guidance code (e.g., 77002, 77012, 76942).
  • Do not report 38222 for obtaining bone marrow for transplantation or stem cell harvest; refer to codes 38205-38206 for these procedures.
  • The collection of samples for additional studies like flow cytometry, cytogenetics, or FISH during the biopsy does not change the CPT code for the biopsy itself; these laboratory tests are coded separately.

Associated ICD-10 Codes