CCANTER
Networker
i am not sure what cpt code to use on this i thought originally 19083 but since the patient' is status post mastectomy.
20206 i thought but i dont feel like it was muscle
Operative Note
Preop Diagnosis: BIRADS 4c left Chest Mass, palapable
Postop Diagnosis: Same
Procedure: Ultrasound-guided left breast core needle biopsy
Biopsy Device: 16G Bard Max-Core
Indications / Findings:
a suspicious BI-RADS 4 lesion in the left anterior chest at on ultrasound s/p mastectomy for triple negative breast cancer.
Operative Details:
The ultrasonographer located the lesion. Preliminary ultrasound evaluation of the left chest with special attention to the area of concern, confirms the presence of a mass which is also palpable.
The breast was then prepped and draped in usual sterile fashion and a timeout was taken to confirm the correct procedure and position.
Local anesthetic was infiltrated in the skin just superior to the lesion. An 11 blade was used to nick the skin. The ultrasound was oriented and in an antiradial position. From a lateral approach, a 16-gauge core needle on the Bard Max-Core spring loaded device was advanced to the preselected target. I tracked the needle in plane.
A total of 4 biopsy specimens were obtained, with pre- and post-fire ultrasound images documenting needle placement for each pass. Specimens were sent for pathologic analysis, results pending. The biopsy appeared accurate.
this is what the path showed
A. LEFT BREAST MASS, PROCEDURE NOT SPECIFIED:
FIBROUS AND ADIPOSE TISSUE CONSISTENT WITH SCAR.
NO ORGANOID BREAST TISSUE IS IDENTIFIED.
20206 i thought but i dont feel like it was muscle
Operative Note
Preop Diagnosis: BIRADS 4c left Chest Mass, palapable
Postop Diagnosis: Same
Procedure: Ultrasound-guided left breast core needle biopsy
Biopsy Device: 16G Bard Max-Core
Indications / Findings:
a suspicious BI-RADS 4 lesion in the left anterior chest at on ultrasound s/p mastectomy for triple negative breast cancer.
Operative Details:
The ultrasonographer located the lesion. Preliminary ultrasound evaluation of the left chest with special attention to the area of concern, confirms the presence of a mass which is also palpable.
The breast was then prepped and draped in usual sterile fashion and a timeout was taken to confirm the correct procedure and position.
Local anesthetic was infiltrated in the skin just superior to the lesion. An 11 blade was used to nick the skin. The ultrasound was oriented and in an antiradial position. From a lateral approach, a 16-gauge core needle on the Bard Max-Core spring loaded device was advanced to the preselected target. I tracked the needle in plane.
A total of 4 biopsy specimens were obtained, with pre- and post-fire ultrasound images documenting needle placement for each pass. Specimens were sent for pathologic analysis, results pending. The biopsy appeared accurate.
this is what the path showed
A. LEFT BREAST MASS, PROCEDURE NOT SPECIFIED:
FIBROUS AND ADIPOSE TISSUE CONSISTENT WITH SCAR.
NO ORGANOID BREAST TISSUE IS IDENTIFIED.