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Help Please - what CPT to use???

  1. #1
    Location
    Richmond Virginia
    Posts
    501
    Default Help Please - what CPT to use???
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    Opinions on what CPT to use??? Thanks

    EXAMS:004086673 CT GUIDED BIOPSY

    Informed consent was obtained. Mass in the right side of the rectum
    extending into the perirectal fat was localized under CT guidance
    with the patient in the prone position. 1% lidocaine was used for
    superficial local anesthesia. Two core biopsies were obtained through
    the mass with an 18-gauge Biopince needle through a 17-gauge coaxial
    needle. The patient tolerated the procedure well without immediate
    complication. Pathology reports that specimen is adequate.

    Impression: CT-guided percutaneous biopsy of right-sided rectal and
    perirectal mass.

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by RadMedCoder View Post
    Opinions on what CPT to use??? Thanks

    EXAMS:004086673 CT GUIDED BIOPSY

    Informed consent was obtained. Mass in the right side of the rectum
    extending into the perirectal fat was localized under CT guidance
    with the patient in the prone position. 1% lidocaine was used for
    superficial local anesthesia. Two core biopsies were obtained through
    the mass with an 18-gauge Biopince needle through a 17-gauge coaxial
    needle. The patient tolerated the procedure well without immediate
    complication. Pathology reports that specimen is adequate.

    Impression: CT-guided percutaneous biopsy of right-sided rectal and
    perirectal mass.
    Looks to me like the closest procedure is 49180 and it includes radiologic guidance.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #3
    Location
    Alexandria, LA
    Posts
    518
    Default
    Quote Originally Posted by ajs View Post
    Looks to me like the closest procedure is 49180 and it includes radiologic guidance.
    49180 does not include radiologic guidance. See the parenthetical note after 49180 that says to add the guidance.

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