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Hello,
I was hoping that I could get some assistance as to how to code a CT guided biopsy of a porta hepatis mass (small snip of report below.)
The initial coding that was entered was 20206 and 77012 but after reviewing the report below I feel that this should be coded under 47000 and 77012. I haven't really coded this type of procedure but would like some thoughts as to if I'm correct, on the right track or if the procedure should be coded under something else. Education/assistance is greatly appreciated!
The procedure description:
A timeout procedure was performed. The patient was attached to continuous physiologic monitoring throughout the procedure. A limited CT was used to localize the porta hepatis mass. The site was prepped and draped in the usual sterile fashion. The skin and subcutaneous tissues were anesthetized with 1% lidocaine without epinephrine. A 17-gauge coaxial needle was advanced to the periphery of the lesion under CT guidance. 18-gauge core biopsies were then obtained using a coaxial technique. Core specimens were placed in formalin and RPMI. The coaxial needle was removed. Hemostasis was achieved with manual compression. A sterile dressing was applied. After the biopsy was performed, a limited follow-up CT was performed demonstrating no evidence of complication. The patient tolerated the procedure well. There were no immediate complications.
Findings:
Limited CT demonstrated an ovoid mass in the porta hepatis measuring approximately 5.9 x 2.3 cm. Moderate upper abdominal ascites is noted. Intraprocedural CT images demonstrated good position of the coaxial needle at the periphery of the lesion.
Impression:
Uncomplicated CT-guided biopsy of a porta hepatis mass.
I was hoping that I could get some assistance as to how to code a CT guided biopsy of a porta hepatis mass (small snip of report below.)
The initial coding that was entered was 20206 and 77012 but after reviewing the report below I feel that this should be coded under 47000 and 77012. I haven't really coded this type of procedure but would like some thoughts as to if I'm correct, on the right track or if the procedure should be coded under something else. Education/assistance is greatly appreciated!
The procedure description:
A timeout procedure was performed. The patient was attached to continuous physiologic monitoring throughout the procedure. A limited CT was used to localize the porta hepatis mass. The site was prepped and draped in the usual sterile fashion. The skin and subcutaneous tissues were anesthetized with 1% lidocaine without epinephrine. A 17-gauge coaxial needle was advanced to the periphery of the lesion under CT guidance. 18-gauge core biopsies were then obtained using a coaxial technique. Core specimens were placed in formalin and RPMI. The coaxial needle was removed. Hemostasis was achieved with manual compression. A sterile dressing was applied. After the biopsy was performed, a limited follow-up CT was performed demonstrating no evidence of complication. The patient tolerated the procedure well. There were no immediate complications.
Findings:
Limited CT demonstrated an ovoid mass in the porta hepatis measuring approximately 5.9 x 2.3 cm. Moderate upper abdominal ascites is noted. Intraprocedural CT images demonstrated good position of the coaxial needle at the periphery of the lesion.
Impression:
Uncomplicated CT-guided biopsy of a porta hepatis mass.