Radiology Coding Alert

Use this biopsy case study to get your AAPC continuing-education credits Learn how to navigate your way through real Radiology reports with our experts' advice. We'll tell you how to look for potential problems and what to do when you find them. Get to the Core of the Problem DICTATED REPORT: CT-Guided Liver Core Biopsy

Initially a direct anterior approach to the lateral segment left-lobe lesion was used. A 19-gauge coaxial needle was advanced into the periphery of the lesion. A core biopsy could not be performed from this projection because the throw of the needle would probably traverse the entire AP diameter of the liver and enter the stomach in this thin lateral section of the liver. Therefore, an oblique approach was used. Eventually a coaxial 19-gauge needle was advanced into the mass. Three 19-gauge core specimens were obtained and placed in formalin. There is no hematoma on the post-biopsy CT scan.

Impression:

1. Three 19-gauge core samples of the mass in the left lobe of the liver were obtained.

2. If the pathology report is benign, the patient should have a follow-up MRI in three months to verify that both this lesion and the right-lobe lesion are stable.

Addendum: Path report - benign. Solution: One way to begin is to quickly read through the report to determine the general procedure involved, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver. After you skim through the documentation, you can "go back through looking for the specifics."

In this case, Hammer notes a successful core needle biopsy. With this in mind, you can go through the report and try to answer certain questions. Hammer suggests these:

What mass/anatomic site is being biopsied?

Via what technique - fine needle, core needle, percutaneous, open?

How many biopsy samples were taken?

What form of radiology visualization was used?

What were the findings?


This report indicates "lateral segment left-lobe lesion." The core needle via the oblique approach produced three viable specimens, Hammer says. The first line indicates that the procedure used CT guidance.

Informed ICD-9: Obtain the post-pathology reading to document the diagnosis when the report isn't detailed enough, Hammer says. In this sample, the addendum states that the liver lesion is benign, so report 211.5 (Benign neoplasm of other parts of digestive system; liver and biliary passages). A more specific diagnosis than "benign" is even better. Ask the doctor to include the actual diagnosis (for example, adenoma or focal nodular hyperplasia) for the most accurate report.

"It is always best to use a specific diagnosis versus an unspecific one when possible," says Debbie Campbell, vice president of Medical Business Office Inc. in Jefferson City, Mo.

Choosing CPT: You know the physician obtained "three 19-gauge [...]