Wiki Help Please - what CPT to use???

[Lynda Wetter]

Opinions on what CPT to use??? Thanks

EXAMS:004086673 CT GUIDED BIOPSY

Informed consent was obtained. Mass in the right side of the rectum
extending into the perirectal fat was localized under CT guidance
with the patient in the prone position. 1% lidocaine was used for
superficial local anesthesia. Two core biopsies were obtained through
the mass with an 18-gauge Biopince needle through a 17-gauge coaxial
needle. The patient tolerated the procedure well without immediate
complication. Pathology reports that specimen is adequate.

Impression: CT-guided percutaneous biopsy of right-sided rectal and
perirectal mass.

 

[ajs]

Opinions on what CPT to use??? Thanks

EXAMS:004086673 CT GUIDED BIOPSY

Informed consent was obtained. Mass in the right side of the rectum
extending into the perirectal fat was localized under CT guidance
with the patient in the prone position. 1% lidocaine was used for
superficial local anesthesia. Two core biopsies were obtained through
the mass with an 18-gauge Biopince needle through a 17-gauge coaxial
needle. The patient tolerated the procedure well without immediate
complication. Pathology reports that specimen is adequate.

Impression: CT-guided percutaneous biopsy of right-sided rectal and
perirectal mass.

Looks to me like the closest procedure is 49180 and it includes radiologic guidance.

 

[donnajrichmond]

Looks to me like the closest procedure is 49180 and it includes radiologic guidance.

49180 does not include radiologic guidance. See the parenthetical note after 49180 that says to add the guidance.