Medical coding Sample Report 1
EXAM: MAMMO US BIOPSY LYMPH NODE RT
COMPARISON: None
REASON FOR EXAM: N63.10-Breast mass, right
ADDITIONAL HISTORY: .
INFORMED CONSENT: Prior to the procedure in an non-coercive space, the patient was advised as to the nature of the procedure including placement of markers, alternatives, benefits, and risks including but not limited to bleeding, pain, infection, scarring and non-diagnosis. The patient was encouraged to ask further questions and those questions and concerns were addressed. The patient freely gave informed consent without guarantees.
PREPROCEDURAL BRIEFING: The patient and technical staff were briefed as to the correct patient, side, site, and technique of procedure and all were in agreement to proceed.
TECHNIQUE: Sonographic imaging for lesion identification and localization.
PROCEDURE DETAILS: The skin was prepped and draped in usual sterile fashion with ChloraPrep. Following cutaneous anesthesia with 2 mL buffered lidocaine and additional deeper anesthesia with 4 mL buffered lidocaine with epinephrine, a plunge incision was made. A core biopsy needle was then passed through the plunge incision and under ultrasound visualization brought to position with core samples obtained.
A 9 gauge needle was used.
The approach utilized was lateral to medial.
Number of core sample obtained: 2
Estimated percent of target excised: 75%
Marker shape, model, manufacturer: Marker Style: Hologic X. Marker
Specimen Radiograph: Not performed.
POST BIOPSY DIGITAL MAMMOGRAPHY: Following successful completion of the ultrasound guided core biopsy, a
digital breast Tomosynthesis of the Right breast was obtained demonstrating the target site marker in
place with 0 mm of displacement from the target site.
Pressure was held at the biopsy site and hemostasis was achieved. The skin incision was closed with Steri-Strips. The patient was given verbal and written post-procedural instructions. The patient tolerated the procedure well without significant complication. In coordination with the patient and their primary care provider, follow up and pathology review were scheduled or orchestrated to the patient’s needs and provided in written and verbal format.
Impression:
Technically successful ultrasound-guided biopsy of the 5 mm enhancing oval vascularized hypoechoic mass at the axillary tail location of the Right breast.
A post biopsy pathology review and addendum will follow.
EXAM: MAMMO US BIOPSY LYMPH NODE RT
PATHOLOGY CLASS: Benign
PATHOLOGY RESULT: Reactive intramammary lymph node without atypia or
evidence of metastatic malignancy
CONGRUENCY: Congruent
CPT & ICD 10 codes:
38505 Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary)
76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation
N6310 Unspecified lump in the right breast, unspecified quadrant
Medical coding Sample Report 2
EXAM: US GUIDE NEEDLE PLACEMENT
REASON FOR EXAM: R59.0-Axillary lymphadenopathy
ADDITIONAL HISTORY: .
TECHNIQUE: Real-time grayscale sonographic images of the thyroid gland and associated nodule with
color/Doppler imaging.
PROCEDURE:
Patient was brought to the ultrasound suite and placed in the supine position with the right axilla exposed. Preprocedural images demonstrated the right axillary adenopathy and the safest and most
appropriate trajectory for biopsy was determined. The plan was reviewed with the patient, including the risks and benefits. Risks mentioned but not limited to, included bleeding, infection and damage to adjacent neurovascular and pulmonary structures; patient understood the risks and decided to proceed with the procedure. All patient questions were answered to their satisfaction prior to biopsy. Patient provided a written and verbal consent; written consent was placed in the patient’s chart. A timeout was performed with all staff members present.
The right axilla was prepped and draped in the standard usual fashion. 1% local lidocaine was infiltrated into the subcutaneous tissues under direct ultrasound guidance. 1 pass utilizing a 25-gauge, 1.5 inch needle was performed utilizing both aspiration and capillary action technique; this pass was performed under direct ultrasound guidance. Following the initial fine needle aspiration, 2 18-gauge core biopsy samples were obtained through the largest most suspicious right axillary lymph node. The samples were passed to the pathologist who was present in the room for the examination. Following the biopsy, hemostasis was obtained. Patient tolerated the procedure well, without evidence of immediate
complication.
Postprocedural imaging was performed demonstrating no evidence of postprocedural complication. Patient was given discharge instructions, by our department nurse, the patient was discharged in stable
condition.
FINDINGS:
Right axillary lymphadenopathy.
Impression:
1. Successful ultrasound-guided fine-needle aspiration and core needle biopsy of the right axillary adenopathy. Await histopathological analysis.
FINAL DIAGNOSIS
1. LYMPH NODE, BIOPSY, RIGHT AXILLARY :
INCREASED NUMBERS OF CD5/CD23-POSITIVE B-CELLS, SUSPICIOUS FOR INVOLVEMENT BY
SMALL LYMPHOCYTIC LYMPHOMA/CHRONIC LYMPHOCYTIC LEUKEMIA
CPT & ICD 10 codes:
10005 Fine needle aspiration biopsy, including ultrasound guidance; first lesion
R590 Localized enlarged lymph nodes
Medical coding Sample Report 3
EXAM: XR ARTHROGRAM SHOULDER LEFT
COMPARISON: None
REASON FOR EXAM: M25.512-Chronic left shoulder pain
TECHNIQUE: Informed consent was obtained. Patient’s left shoulder was prepped and draped in a sterile
manner and anesthetized with 1% Lidocaine. Using fluoroscopic guidance a needle was placed into the joint space and a mixture of 10 cc of Isovue 300, 0.2% Ropivacaine and 0.1 cc of gadolinium was also
introduced.
FLUORO TIME (In Minutes, Seconds): 1 min and 10 seconds
FINDINGS:
Marginal osteophyte along the inferior margin of the glenohumeral joint.
There is no extravasation of contrast from the glenohumeral joint into the subdeltoid or subacromial bursa.
Impression:
1. Degenerative spurring along the inferior margin of the humerus.
2. No rotator cuff defect identified during arthrogram.
CPT & ICD 10 codes:
23350-LT Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography
73040-LT Radiologic examination, shoulder, arthrography, radiological supervision and interpretation
Medical coding Sample Report 4
EXAM: US ASPIRATION ABDOMEN
COMPARISON: None
REASON FOR EXAM: K76.9-Liver disease
ADDITIONAL HISTORY: Cytology, c and s, Cell count.
TECHNIQUE: Real-time grayscale sonographic images were performed of the 4 quadrants of the abdomen, for
preprocedural planning. No color/spectral Doppler imaging was obtained.
PROCEDURE: The procedure was explained to the patient and informed consent was obtained. History and physical and laboratory data were reviewed. Timeout was performed. Ultrasound was used to localize a
pocket of fluid amenable to drainage. The skin overlying the Right lower quadrant quadrant was prepped and draped in the usual sterile fashion. It was infiltrated with 1% lidocaine, and a small incision was made, through which a 5 French Yueh catheter was inserted and advanced slowly until fluid could be aspirated into a syringe. The catheter was advanced as the inner stylet was removed, and the catheter was
connected to a Vacutainer bottle. A total of 1700 ml of clear yellow fluid was collected. Fluid was sent to laboratory for evaluation. The catheter was removed, and a completion survey with ultrasound was
performed. The patient tolerated the procedure well.
FINDINGS: The initial ultrasound survey demonstrates a large quantity of intraperitoneal free fluid/ ascites, with subsequent images demonstrating complete resolution after paracentesis.
Impression:
1. Successful ultrasound-guided paracentesis.
CPT & ICD 10 codes:
49083 Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance
K769 Liver disease, unspecified
Medical coding Sample Report 5
EXAM: CT GUIDED BIOPSY
COMPARISON: None
REASON FOR EXAM: C90.30-Neoplasm of uncertain behavior of plasma cells
ADDITIONAL HISTORY: Targeted CT scan-guided bone marrow biopsy of specific lesions seen on PET-CT scan,
Evaluate for prostate cancer versus multiple myeloma versus other.
TECHNIQUE: Informed consent was obtained at patient was explained risks benefits and alternatives to CT-guided biopsy of the bony pelvis.
Patient was placed in the CT scanner in the prone position.
Patient’s lower lumbar spine region was prepped and draped in a sterile manner and anesthetized with 1% lidocaine.
Using CT guidance a bone biopsy needle was placed immediately adjacent to a hypodense nodule within the right ilium and 2 core specimens were obtained. Bone marrow aspiration was also obtained from the right ilium.
Using CT guidance a bone biopsy needle was used to obtain a core specimen from a lesion present within the left ilium.
FINDINGS:
Numerous small lytic lesions present within the bones of the pelvis.
Impression:
1. Status post CT-guided biopsy of lytic lesions within the right and left ilium as well as bone marrow
aspirate from the right ilium.
CPT & ICD 10 codes:
38222 Diagnostic bone marrow; biopsy(ies) and aspiration(s)
77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation