Shirleybala
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Hello:
Can we code it as muscle biopsy 20206
Large anterior abdominal wall mass. Referred for ultrasound
guided core biopsy, rule out sarcoma versus lymphoma versus
metastatic disease.
On physical examination, there is a large protuberant very firm
mass arising from the upper anterior abdominal wall. The site was
prepped and draped in usual sterile manner and locally
anesthetized with 1% lidocaine. Under real-time ultrasound
guidance a 17-gauge guiding needle was advanced into the lesion.
An image was stored and documented for the medical record.
A total of 5 coaxial 18-gauge core biopsies were obtained, two
placed in formalin and 3 placed in RPMI. Touch prep was reviewed
with the attending pathologist confirming lesional tissue.
At the end of the procedure the needle was removed and hemostasis
achieved with manual compression. A sterile dressing was applied.
The patient tolerated the procedure well, left prominent stable
condition.
Impression:
Ultrasound guided core biopsy large protuberant anterior abdominal
mass, 18-gauge core 5 passes. No immediate complications. Final
pathology results pending.
Can we code it as muscle biopsy 20206
Large anterior abdominal wall mass. Referred for ultrasound
guided core biopsy, rule out sarcoma versus lymphoma versus
metastatic disease.
On physical examination, there is a large protuberant very firm
mass arising from the upper anterior abdominal wall. The site was
prepped and draped in usual sterile manner and locally
anesthetized with 1% lidocaine. Under real-time ultrasound
guidance a 17-gauge guiding needle was advanced into the lesion.
An image was stored and documented for the medical record.
A total of 5 coaxial 18-gauge core biopsies were obtained, two
placed in formalin and 3 placed in RPMI. Touch prep was reviewed
with the attending pathologist confirming lesional tissue.
At the end of the procedure the needle was removed and hemostasis
achieved with manual compression. A sterile dressing was applied.
The patient tolerated the procedure well, left prominent stable
condition.
Impression:
Ultrasound guided core biopsy large protuberant anterior abdominal
mass, 18-gauge core 5 passes. No immediate complications. Final
pathology results pending.