General Surgery Coding Alert

Reader Questions:

Be Aware of Bilateral Breast Documentation

Question: A provider conducted a fine needle aspiration (FNA) biopsy on both breasts using ultrasound guidance (US). The surgical report provides an in-depth description of the procedure performed on the right breast, but only mentions that “a comparable procedure was carried out on the left breast.” Is this enough documentation to support a bilateral procedure? If so, how should I report [...]
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