# First time coding this type of report...help



## vicky74 (Jul 1, 2015)

This is the first time I have coded this type of report.  I'm confused on how many times I report the aspiration of the cysts. and do I code with a 50 modifier on all procedure codes? 


EXAMINATION: BILATERAL BREAST CYST ASPIRATION

DATE: 6/29/2015

HISTORY: Bilateral breast cysts.

COMPARISON: Breast ultrasound 6/11/2015.

FINDINGS:
Written consent was obtained. Breasts were prepped and draped in a sterile
fashion. 2% Xylocaine with bicarbonate was used for local anesthesia. Using an
18-gauge needle, 3 right-sided breast cysts were aspirated at the 10:30 o'clock
position approximately 8 cm from nipple. The cysts contained clear tan fluid.
Post aspiration images show complete resolution of cysts.

Next, 2% Xylocaine with bicarbonate was used for local anesthesia and aspiration
of 3 left-sided breast cyst was performed using 18-gauge needle. 2 of the cysts
completely collapsed and demonstrate clear tan fluid. The third cyst did not
completely collapse and contained thick white fluid, which was sent for
cytology. Area was dressed in a sterile fashion. Patient tolerated procedure
well.


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## jdibble (Jul 8, 2015)

vicky74 said:


> This is the first time I have coded this type of report.  I'm confused on how many times I report the aspiration of the cysts. and do I code with a 50 modifier on all procedure codes?
> 
> 
> EXAMINATION: BILATERAL BREAST CYST ASPIRATION
> ...



The codes in the CPT book for Puncture aspiration of breast cysts tell you what codes you need! This appears to be code 19000. If you look up that code you will see code 19001 below that states "each additional cyst". You would code 19000 once and then 19001 x 5. You would not need the 50 modifier with this code.

Hope that helps.


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