Wiki Stereotactic Views without Biopsy

[drobinson1]

Hello fellow coders. My manager and I have a question about stereotactic views taken when the biopsy is not done. We thought about charging an E/M service but I would really appreciate someone's advice. The report reads:

69-year-old female with history of right mastectomy approximately 20 years ago. Her most recent mammogram of reveals new microcalcification cluster in the upper posterior left breast, for which tissue sampling is needed. There was a questionable very subtle associated mass in this area as well. The patient presented for stereotactic biopsy. The procedure, its risks and benefits were explained in detail to the patient,who gave written informed consent. The patient was placed in the dedicated prone stereotactic unit, and a series of numerous scout and stereotactic image pairs were performed in multiple different projections. Unfortunately, given the patient's anatomy and overlying vessels, it was not possible to localize the microcalcifications with adequate breast compression and safely avoid overlying vessels. This was discussed in detail with the patient, who will be consulting with her surgeon to arrange for needle localization and excisional biopsy.


IMPRESSION:
Stereotactic biopsy of left breast microcalcifications was not technically possible, as detailed above. This procedure was discussed with her surgeon Dr. Boraas on 4/20/2010

 

[SharL]

Stereotactic vws w/o biopsy

I code for outpatient hospital. This happens often for one reason or another. I look at each report to determine exactly what we did. If we did not puncture the skin to attempt to do invasive component, we generally full discount the procedure if only scout imaging was done. These patients typically have had mammograms already and/or some other diagnostic exam, (ultrasound or MRI) in order to get to this point. Many times the patient will be rescheduled and return for another attempt, and if successful we would code out that one.

Correct coding allows the 52, I believe, but we only modify it that way if the skin was actually punctured.

I'd like to know what others are doing as well as this has always been one of those controversial topics.