Wiki Prostate Biopsy

[msingh23]

I'm trying to figure which biopsy procedure was done? Transperineal stereotactic or Percutaneous Biopsy

Procedure Needle Procedure:
Indications:
Biopsy: surveillance biopsy
Antibiotics prior to procedure: Yes
Antibiotics: ancef
Procedure:
Procedure performed: transperineal prostate needle biopsy

Procedure statement:
Transperineal Prostate needle biopsy: The history and physical exam was reviewed. He was brought into the operating room. A timeout was performed. Perioperative antibiotics were given. He was placed in dorsal lithotomy. The perineum was prepped and sterilized. Anesthesia was administered with monitored anesthesia care. The Ultrasound probe was inserted gently and prostate visualized. We obtained biopsies of the regions of interest on the MRI using a transperineal technique. The probe was removed, and no mucosal injuries were identified. Patient tolerated the procedure.

Transrectal Ultrasound Percutaneous Guided Biopsy:
Systematic: #10 cores
MRI Interpretation and Countouring:
MRI interpretation and contouring: Yes
MRI interpretation and contouring comment: The MRI was annotated, a. The ultrasound and MRI images were fused after contouring was performed.
Thank you for your suggestions.

 

[AltheaConklin]

I encourage you to query as it's the only way you'll know for sure.

Disclaimer: This is not my wheelhouse...my understanding is there are some typical differences between the two approaches (and I'm hopeful someone with better working knowledge will respond to you). First, transrectal biopsies are generally in office, local anesthetic biopsies. Transperineals are generally sedation/general anesthesia procedures done in ambulatory centers/hospitals. Transrectals in office often use the left lateral decubitus position rather than the dorsal lithotomy although either can be used. Both approaches can use prophylactic antibiotics, but it is transrectals that necessitate trying to mitigate any bacterial transfer from the rectal wall into the prostate.

The report lists this "procedure" as a "transperineal" done in the operating room with the "perineum...prepped and sterilized" under "monitored anesthesia care" with "obtained biopsies...using a transperineal technique". The only place in your report noting "transrectal" is one line (but that is all you need to question this!)

Bottom line is, without querying, you'd be coding it based on a lot of assumptions without definitive information which makes for a lot of opportunity to get it wrong.