19000, 19001 x 2.............would it be appropriate to code 76645? Also would it be corrected to code 76942 x 3???
CLINICAL INDICATION: Left breast pain, 12-1 o'clock axis. Complex cyst seen at sonography
PROCEDURE/FINDINGS: After the risk, benefits, and alternatives of ultrasound-guided cyst aspiration were discussed with the patient, informed consent was obtained. Re-evaluation of the left breast was performed and reveals complex cyst to stil be present measuring 0.5 x 0.7 x 0.7 cm currently 12 o'clock peri areolar. In addition, simple cysts are identified at the 1 o'clock axis, present previously.
Ultrasound-guided need placement x 3 cyst puncture x 3 performed.
Using the usual sterile technique and ultrasound guidance, the previously identified complex cyst in the left breast at the 12 o'clcok asix, periareolar region was aspirated under US guidance, with complete resolution of the cyst. A small volume of milky greenish fluid aspirated. subsequently, similar technique and under US guidance, two adjacent cysts, in the left breast at the 1 o'clock asix were aspirated, with complete resolution of cysts, and acquisition of small volumes of milky fluid. specimens were discarded, compatible with benign aspirate, based on their appearance. The patient tolerated the procedure well and was discharged home in stable condition with verbal discharge instructions.
IMPRESSION: Successful US-guided cyst aspiration of three cysts, within the left breast, one at the 12 o'clock asix, complex, and two in the 1 o'clock axis, left breast.
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