Both core needle and FNA is done in same lesion should i code both biopsy or only core biopsy please clarify
Clinical history: 51-year-old male HIV positive with
lymphadenopathy and multiple splenic lesions.. Request is made
for CT guided biopsy.
Technique: Initially the procedure was discussed with the patient
including risks, benefits and alternatives. Risks discussed
included but were not limited to bleeding, infection,
pneumothorax, intra-abdominal organ and vascular injury. The
patient understood, asked appropriate questions \T\ signed
informed written consent.
Preliminary CT was performed with the patient in supine position
and a grid to mark a site for the biopsy. A left upper quadrant
site was marked, prepped and draped in the usual sterile fashion.
The area was locally anesthetized with one percent lidocaine.
Using CT guidance, a 19/20 gauge coaxial core biopsy needle was
advanced, positioned with the tip within a splenic lesion. FNA
was performed using a 21-gauge needle. Biopsy was then performed
with the 20-gauge coaxial core biopsy needle. A total of two
passes were made. Specimen was placed in formalin and RPMI.
Specimen was given to Dr. of Pathology at the time of
procedure, confirming lesional tissue. At the end of the
procedure a sterile dressing was applied. The patient tolerated
the procedure well, and left the department in stable condition.
No immediate complications.
Impression: CT guided core biopsy of splenic lesion with 19/20
gauge coaxial core biopsy system as well as FNA with a 21-gauge
needle. Specimen given to Pathology at time of procedure.
- Medical Coding
- Medical Billing
- Practice Management
- Exam Preparation
- Other Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Software / Digital
- Code Lookup (AAPC Coder)
- Virtual Coding Experience (Practicode)
- E/M Analyzer
- CPT RVU Calculator
- Health Plan Search (Provider Policies)
- Log In / Join