Fine needle aspiration bx with U/S lymph node

cnramsey

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Would it be appropriate to bill 10021 and 10004 due to him not stating in the procedure note used US for guidance of needle. Or should I code 10005 and 10006 since he documented PROCEDURE: Ultrasound-guided fine-needle aspiration of left neck lymph
node x2. This procedure was done in Rural Health Clinic and we own the US machine.

Any help would be greatly appreciated.:confused:

Patient A
Date:

PREOPERATIVE DIAGNOSIS: Malignant-appearing lymphadenopathy of the left
upper neck.

POSTOPERATIVE DIAGNOSIS: Malignant-appearing lymphadenopathy of the
left upper neck.

PROCEDURE: Ultrasound-guided fine-needle aspiration of left neck lymph
node x2.

STAFF SURGEON: M.D.

PROCEDURE: After discussing the procedure with the patient, the left neck was prepped with Betadine prep swab. We then used
ultrasound to examine the left neck region, identified two packets of
lymph nodes, decided to biopsy the lower packet first. I placed a
25-gauge needle into the lymph node packet and aspirated until fluid
was in the hub. I then placed this onto a microscopic slide and spread
it between two different side slides, one was fixed and one was air
dried and I placed the remainder into the CytoLyt solution. I then
changed needle and syringes and aspirated a second higher level lymph
node packet until I got blood return into the hub of the needle.
Again, I placed this on to a slide and spread it between two separate
slides, one was air dried and one was fixed. The remaining solution
was placed into the CytoLyt solution. These were both sent to
pathology. We will await our biopsy results.



_____________________________
M.D.
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