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Aspiration and Biopsy for Vertebral Body

  1. #1
    Default Aspiration and Biopsy for Vertebral Body
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    Hello coders. Hope someone can help me with the following report. I'm questioning whether an aspiration (77003/62267) and a biopsy(77002/20225) are necessary or was this just a biopsy.

    History: Patient is an 80-year old male with a lytic lesion involving T4. THe patient presents for biopsy.

    Using fluroscopic guidance a 17-gauge needle was inserted in the T4 body via a left para-pedicular approach. Through this needle several 22-gauge needles were inserted. The samples were evaluated by cytology. In addition a core biopsy was obtained with a 17-gauge needle. This was sent in formalin to pathology for further evaluation.

  2. #2
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    Birmingham, Alabama
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    Quote Originally Posted by drobinson1 View Post
    Hello coders. Hope someone can help me with the following report. I'm questioning whether an aspiration (77003/62267) and a biopsy(77002/20225) are necessary or was this just a biopsy.

    History: Patient is an 80-year old male with a lytic lesion involving T4. THe patient presents for biopsy.

    Using fluroscopic guidance a 17-gauge needle was inserted in the T4 body via a left para-pedicular approach. Through this needle several 22-gauge needles were inserted. The samples were evaluated by cytology. In addition a core biopsy was obtained with a 17-gauge needle. This was sent in formalin to pathology for further evaluation.
    Although both were performed, the bone biopsy is included (bundles) with the aspiration, and only one fluoro should be charged.

    62267/77003 only.

    HTH
    Danny L. Peoples
    CIRCC,CPC

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