General Surgery Coding Alert

Question: The surgeon performed an ultrasound-guided biopsy of a mass in the patient's left breast. She then performed a cyst aspiration, also with ultrasonic guidance, of two complex cysts in different locations on the breast. The surgeon used needles to reach the mass and cysts in all three of the procedures. Which codes should I report in this case? New York Subscriber Answer: For the biopsy, use codes 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance) and 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). To report the cyst aspirations, use 19000 (Puncture aspiration of cyst of breast), +19001 (... each additional cyst [list separately in addition to code for primary procedure) and 76942 for the guidance for each cyst. Remember: You can only report 19102 once per lesion biopsied, no matter how many core biopsies the physician performed. -- Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.