suec
Guru
How are you coding a mammographic guided breast biopsy. Are you using CPT 19499? Payor denied saying CPT 19081 is the correct code but this is with stereotactic guidance. Thank you
PROCEDURE:
The procedure with its risks of bleeding, infection and insufficient tissue sampling was explained to the patient and an informed consent was obtained by myself.
A "time out" was initiated prior to the procedure, with documentation of the patient's name, DOB, and site of biopsy.
The asymmetric density of concern at 12 o'clock position right breast is targeted with mammographic tomosynthesis from craniocaudal approach.
The breast was cleansed with a Chloro Prep stick. Local anesthesia with buffered lidocaine, deep anesthesia with lidocaine and 1% epinephrine were administered. A dermatome was made on the skin. A 9 gauge ATEC vacuum assisted biopsy device was placed to the calculated depth and six samples were obtained. Following completion of tissue sampling, a tissue marker was deployed at biopsy site.
Postprocedural care administered in usual manner with firm compression applied for 15 minutes and the skin was bandaged.
Postprocedural images document successful sampling of the targeted lesion. Successful deployment of tissue marker which appears satisfactorily positioned. There is no postprocedural hematoma.
IMPRESSION:
CONCLUSION:
Successful mammographic guided core biopsy asymmetry 12 o'clock position right breast. Successful deployment of tissue marker which appears well-positioned. Patient tolerated procedure well without incident. Pathology pending.
PROCEDURE:
The procedure with its risks of bleeding, infection and insufficient tissue sampling was explained to the patient and an informed consent was obtained by myself.
A "time out" was initiated prior to the procedure, with documentation of the patient's name, DOB, and site of biopsy.
The asymmetric density of concern at 12 o'clock position right breast is targeted with mammographic tomosynthesis from craniocaudal approach.
The breast was cleansed with a Chloro Prep stick. Local anesthesia with buffered lidocaine, deep anesthesia with lidocaine and 1% epinephrine were administered. A dermatome was made on the skin. A 9 gauge ATEC vacuum assisted biopsy device was placed to the calculated depth and six samples were obtained. Following completion of tissue sampling, a tissue marker was deployed at biopsy site.
Postprocedural care administered in usual manner with firm compression applied for 15 minutes and the skin was bandaged.
Postprocedural images document successful sampling of the targeted lesion. Successful deployment of tissue marker which appears satisfactorily positioned. There is no postprocedural hematoma.
IMPRESSION:
CONCLUSION:
Successful mammographic guided core biopsy asymmetry 12 o'clock position right breast. Successful deployment of tissue marker which appears well-positioned. Patient tolerated procedure well without incident. Pathology pending.