Oncology & Hematology Coding Alert

Question: The physician performed the following procedure: Office pelvic ultrasound revealed solid and cystic components. Verbal consent obtained prior to procedure. Vulva cleaned with Betadine and 3ml of 0.5 percent Xylocaine with epinephrine injected into left vulva and wheel formed. 18 gauge needle then introduced into cyst with scant material returned. Hemostatic at end of procedure. Specimen sent for cytology. How should I report this?New York SubscriberAnswer: For the CPT® code, you should consider this to be 10021 (Fine needle aspiration; without imaging guidance). The physician appears to have performed the FNA of a cyst of the vulva without image guidance. Image guidance would mean the use of ultrasound to help visualize the procedure, not a diagnostic ultrasound before the procedure, as described in this case. If the physician did use imaging guidance, you would report 10022 (... with imaging guidance).If you are coding the pelvic ultrasound, you'll need to [...]