Wiki breast abscess

[dlb_2000]

With this report, would I code the 2nd attempt or the core biopsy or just the 10160? Thanks for your time.

HISTORY: LEFT BREAST ABSCESS
PROCEDURE: The procedure of ultrasound guided breast abscess
aspiration, alternatives to the procedure, the risks and benefits
associated with the procedure including but not limited to infection,
bleeding, hematoma and inadequate sampling were discussed with the
patient and an informed written consent was obtained. Patient was
shifted to the ultrasound suite and placed in supine position. After
obtaining the localizing images the access site was marked on the
skin. The skin was prepped and draped in the routine sterile fashion.
After administering local anesthesia an 18 gauge spinal needle
aspiration of the left breast abscess at 9:00 were obtained and
approximately 60 cc of thick chocolate pus color was aspirated and
sent for culture and smear and also cytology. No immediate
complication is noted.
IMPRESSION:
1. Successful aspiration of 60 cc's of chocolate color thick pus from
the left breast abscess involving mainly 9:00 through 12:00. Second
attempt for another area was obtained which demonstrates just soft
tissue. In addition a core biopsy of the region was also obtained and
sent in Formalin container to pathology. Result of pathology did not
show atypia.

 

[sbetts]

Hi,
I would not code for the 2nd attempt. I don't see why you can't bill separately for the core biopsy. This report doesn't include the detail that you normally see for breast core biopsies but if it was done I would code it.

Shena Betts, CPC, RCC