Coding of breast biopsy, cyst aspiration and Lymph node biopsy

RIGHT BREAST: 10:00 at 7 cm from the nipple: Invasive ductal carcinoma, preliminary histologic grade 3, ductal carcinoma in situ.

9:30, 10 cm from the nipple: Invasive ductal carcinoma, preliminary  histologic grade 3, ductal carcinoma in situ.

Right axillary lymph node: Invasive carcinoma, compatible with mammary tumor origin.

Additional Findings : None

Procedures:
Ultrasound guided core biopsy of the 9:30 right breast breast.
Ultrasound guided core biopsy of the 10:00 right breast breast.
Ultrasound guided percutaneous core biopsy of a right axillary lymph node.
Ultrasound-guided cyst aspiration left breast
Diagnostic digital mammogram right breast post ultrasound-guided core biopsies.

History: Masses in the upper outer right breast most suspicious in the 10:00 location. Suspicious right axillary lymph node. Small hypoechoic mass 1:00 left breast.

Technique: The procedure was performed by Dr. Warren. Informed consent was obtained. Risks were reviewed. Final verification was performed. Critical pause with patient identification, site, and procedure verification was performed with assisting personnel just prior to the procedure; the patient’s identity was confirmed using 2 identifiers. Reference is made to prior imaging most recent 2/9/2014.

The breasts and right axilla were prepped in sterile fashion. A total of 25 mL of 1% Xylocaine was utilized for local anesthesia.

With ultrasound guidance an 18-gauge needle was passed percutaneously into the targeted 1:00 hypoechoic mass. This was actually a mildly complicated cyst with debris and collapsed with aspiration. There was scant aspiration of serous fluid. There was no adequate fluid for sampling. A Band-Aid was applied on the left breast.

The masses in the 9:30 and 10:00 right breast were localized. Local anesthesia was administered. For each mass small skin nicks were made.

With ultrasound guidance a 13-gauge Marquee coaxial needle was passed percutaneously to the 9:30 mass/nodule. With ultrasound guidance 4 core biopsy samples were obtained utilizing a 14-gauge Marquee biopsy needle by coaxial technique. A ribbon biopsy marker was placed at the biopsy site with ultrasound guidance by coaxial technique. Blood loss was scant. Digital pressure was applied for hemostasis. No complications were encountered. Dermabond was utilized to close the skin nick.

With ultrasound guidance a 13-gauge Marquee coaxial needle was passed percutaneously to the 10:00 mass/nodule. With ultrasound guidance 6 core biopsy samples were obtained utilizing a 14-gauge Marquee biopsy needle by coaxial technique. A coil biopsy marker was placed at the biopsy site with ultrasound guidance by coaxial technique. Blood loss was scant. Digital pressure was applied for hemostasis. No complications were encountered. Dermabond was utilized to close the skin nick.

With ultrasound guidance a 13-gauge Marquee coaxial needle was passed percutaneously to the suspicious right axillary lymph node. With ultrasound guidance 4 core biopsy samples were obtained utilizing a 14-gauge Marquee biopsy needle by coaxial technique. A twirl biopsy marker was placed at the biopsy site with ultrasound guidance by coaxial technique. Blood loss was scant. Digital pressure was applied for hemostasis. No complications were encountered. Dermabond was utilized to close the skin nick.

Overlying bandages were applied.

Digital medial lateral and craniocaudal mammographic images of the right breast were obtained. The ribbon and coil biopsy markers are noted in the expected locations. The twirl biopsy marker is noted in the right axilla.

The patient was given discharge instructions and sent home in satisfactory condition.

Impression:
1. Ultrasound-guided cyst aspiration of the 1:00 left breast.
2. Ultrasound-guided core biopsies of the right breast and axilla. Pathology is pending.

CPT codes:

19083-RT

19084-RT

38505-RT

19000-LT

76942-26

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