Clip placement without a breast biospy

bmkardok

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Hi Everyone,
According to the note below is appears that the surgeon performed an ultrasound guided placement of a clip. Looking back at the patient's history the patient had a core bx on 4/11/12. The clip procedure was performed on 4/30/12. My question is how do I bill for the clip placement since procedure code 19295 is an add-on code?

Thanks in advance for any help you can provide.



Returns for clip placement since is going to start neoadjuvant hormonal tx. No changes, no complaints.

PE: general - wdwn adult nad
HEENT - moist mucus membranes
pulm - chest excursion symmetric
card - warm extremities
breast - no change L9 area
lymph - bilat axillae no nodes palp
m/s no deformities of extremities
skin - no visible lesions/rashes
psych - affect appropriate to interview/situation

sono – no change, irregular hypoechoic mass L9

Proc – sterile prep, sono guidance, placed marker clip at anteromedial edge of mass

f/u mammo for placement

Imp breast CA
Plan return after neoadjuvant

Returns for clip placement since is going to start neoadjuvant hormonal tx. No changes, no complaints.

PE: general - wdwn adult nad
HEENT - moist mucus membranes
pulm - chest excursion symmetric
card - warm extremities
breast - no change L9 area
lymph - bilat axillae no nodes palp
m/s no deformities of extremities
skin - no visible lesions/rashes
psych - affect appropriate to interview/situation

sono – no change, irregular hypoechoic mass L9

Proc – sterile prep, sono guidance, placed marker clip at anteromedial edge of mass

f/u mammo for placement

Imp breast CA
Plan return after neoadjuvant
 
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