Procedure: Ultrasound-guided core needle biopsy right breast at 2 sites, ultrasound-guided core needle biopsy left axillary lymph node, right diagnostic mammogram
HISTORY: 33-year-old woman presents with history of a 25 mm mass of the right breast 10 o’clock position, 7 cm from nipple (site A), 5 mm mass of the right breast 9 o’clock position, 12 cm from nipple (site B), and 31 mm lymph node of the right axilla 12 cm from nipple (site C) for which ultrasound-guided core needle biopsy was recommended.
Study is correlated with outside films for second interpretation/consult breast imaging and ultrasound and compared with prior diagnostic mammography and ultrasound.
Informed consent for the ultrasound-guided core needle biopsy of the right breast and axilla was obtained following a detailed discussion of the risks, benefits, alternatives, and complications. A timeout was performed by the team prior to the procedure to verify patient identity and lesion site.
Site A–right breast 10 o’clock 7 cm from nipple: The ultrasound-guided core needle biopsy of the targeted mass was performed utilizing a 14-gauge mechanical needle under the usual aseptic conditions and following administration of 16 cc 1% lidocaine soluton as a local anesthetic. A series of 5 core needle samples were obtained under ultrasound guidance. A ribbon-shaped metal tissue marker was deployed centrally within the mass under ultrasound guidance.
Site B–right breast 9 o’clock 12 cm from nipple: The ultrasound-guided core needle biopsy of the targeted mass was performed utilizing a 14-gauge mechanical needle under the usual aseptic conditions and following
administration of 13 cc 1% lidocaine solution as a local anesthetic. A series of 5 core needle samples were obtained under ultrasound guidance. A coil-shaped metal tissue marker was deployed centrally within the mass under ultrasound guidance.
Site C–right axilla 12 cm from nipple: The ultrasound-guided core needle biopsy of the targeted mass was performed utilizing a 14-gauge mechanical needle with coaxial zero throw technique and under the usual aseptic conditions and following administration of 23 cc 1% lidocaine solution as a local anesthetic. A series of 5 core needle samples were obtained under ultrasound guidance. A twirl ring-shaped metal tissue marker was deployed centrally within the mass under ultrasound guidance.
The patient tolerated the procedure well without complications.
Post procedure right ML, MLO, and CC digital mammographic views were performed to confirm clip position and not for diagnostic purposes and demonstrate minimal post biopsy change and successful deployment of the metal tissue markers in good position within the breast and axilla.
IMPRESSION: Successful ultrasound-guided core needle biopsy of the right breast and axilla. Final pathology is pending.
CPT 19083-RT Biopsy, breast, with placement of breast localization device(s) (eg,clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including
ultrasound guidance
CPT 19084–RT Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion,
including ultrasound guidance (List separately in addition to code for primary procedure)
CPT 38505– Biopsy or excision of lymph node(s); by needle, superficial (e.g., cervical, inguinal, axillary)
CPT 77065 –26,RT– Diagnostic mammogram