Wiki Needle Core Breast Biopsy with Ultrasound Guidance

[Jane Webb]

My physician documents in office procedure:
Core needle biopsy performed in clinic. Her note states - After the area was prepped and draped in the usual sterile fashion local anesthetic was injected at the site of the mass. The mass was located using ultrasound. The mass had irregular boarders and measured 2 cm. Using ultrasound guidance the 18 G needle biopsy was taken. 3 separate core samples were taken. Pressure was held at the insertion site for 5 minutes.

The CPT code book says 19100 is without ultrasound guidance. 19083 seems like it is too much as no localization markers were placed. Can an 18 gauge needle be considered 'fine needle aspiration' as in 10005? Any suggestions?

 

[EstherImmanuel]

CPT 19083 would be the right code.
Please refer the CPT description as "Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance". It says " when performed" hence it is not mandatory that the localization devices should be placed.
Hence 'with\without' placement of localization devices and 'with\without' of imaging specimen, if the biopsy performed by US guidance ,you can go ahead and code with CPT 19083.

Thanks,
Esther Immanuel.