Medical coding Sample coded Report – 1

US BREAST BIOPSY RIGHT 

HISTORY: Suspicious 11 mm solid palpable lesion 5:00 6 cm from the nipple. 

PROCEDURE: Risks and procedure were discussed with the patient in Spanish and written informed consent was obtained.

The right breast was prepped and draped in the usual manner.  Buffered 1% lidocaine was used for skin anesthesia followed by buffered 1% lidocaine mixed with epinephrine for deeper anesthesia.  Small skin incision made.  Under sonographic guidance, a Suros 12-guage vacuum assisted core biopsy needle device was then used to obtain six core samples of the solid mass at 5:00 6 cm from the nipple.  A clip was placed at the site of biopsy via the Suros device. The needle was withdrawn and pressure applied to ensure adequate hemostasis. Minimal blood loss noted, no complication, and the patient was without complaint.  Patient was provided postprocedural precautions verbally and in writing and will be notified via telephone once pathology results are made available.  

SUMMARY: Ultrasound-guided vacuum assisted core biopsy of the right breast.

CPT – 19083-RT

ICD 10 – N63.10

Medical coding Sample coded Report – 2

NEEDLE WIRE LOCALIZATION, RIGHT BREAST
INDICATION: Carcinoma in situ of breast, right

HISTORY: Malignancy in the inferior medial right breast. The target is a metallic clip and some residual calcifications.

TECHNIQUE: Using digital technique, the lesion in question was imaged. Using a medial approach, a 21 gauge needle was placed adjacent to the lesion. 0.3 ml of methylene blue were injected at the needle tip. The needle was replaced with the hook wire. The patient tolerated the procedure well. Subsequent mammography reveals that the wire is adjacent to the area in question.

IMPRESSION: Successful needle wire localization of the right breast lesion.

CPT – 19281-RT

ICD 10 – D05.91

Medical coding Sample coded Report – 3

PROCEDURE: CT GUIDED RIGHT UPPER LOBE LUNG BIOPSY

HISTORY:  Enlarging Right Upper Lobe Lung mass, Clinical conern for Malignancy

COMPLICATIONS: None.

PROCEDURE DESCRIPTION: After obtaining informed consent in a SPARQ conference, the patient was prepped and draped in the usual sterile fashion. The right upper lobe mass was localized under CT guidance and the skin was anesthetized with 1% lidocaine. Subsequently, a 18 gauge introducer needle was advanced into the mass under CT guidance. Three 20 gauge core biopsies were performed. Samples were placed in both sterile saline and formalin and sent to pathology for further evaluation.

Post biopsy completion imaging was performed. The patient tolerated the procedure well and without complication.

FINDINGS: CT imaging again demonstrates a mass within the lateral aspect of the right upper lobe.  Imaging demonstrates appropriate positioning of the biopsy needle within this lesion to allow tissue sampling. Completion imaging demonstrates ground-glass opacities surrounding the biopsy site compatible with hemorrhage. There is no pneumothorax.

IMPRESSION: Technically successful CT guided right upper lobe lung biopsy.

CPT – 32408

ICD 10 – J98.4

Medical coding Sample coded Report – 4

INDICATION: Malignant neoplasm of breast (female), unspecified site (HCC)

SENTINEL NODE INJECTION, right breast The procedure was performed by Dr. Richard. Following sterile preparation of the skin, a total of 0.55 mCi of Technetium sulfur colloid was injected into the right periareolarbreast in four separate aliquots. She tolerated this well.

CPT – 38792

ICD 10 – C50.911

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