Please advise how you would code this for MEDICARE:
EXAM:
MAMMOGRAM BILATERAL POST BIOPSY; ULTRASOUND GUIDED BREAST BIOPSY ADDITIONAL SITE; ULTRASOUND GUIDED BREAST BIOPSY BILATERAL
HISTORY:
Bilateral abnormalities identified on outside diagnostic MRI. Second-look ultrasound reveals multiple findings warranting further evaluation with ultrasound-guided core biopsy, detailed below.
PROCEDURE:
The details of the procedure were discussed with the patient and the risks, benefits and alternatives were explained. Her consent was documented.
Sample A right breast 8 oclock: The skin was prepped in the usual sterile fashion. The lesion at 8 oclock was located with direct ultrasound visualization. The skin and deeper tissues were anesthetized with 1% Xylocaine and a 14 gauge biopsy needle was advanced to the lesion through a small skin incision. 5 samples were obtained and sent to pathology in formalin. A linear, stoplight shaped metallic marker was left at the biopsy site. Hemostasis was achieved with several minutes of manual compression. The patient tolerated the procedure well.
Sample B palpable mass left breast 3 oclock: The skin was prepped in the usual sterile fashion. The lesion at 3 oclock was located with direct ultrasound visualization. The skin and deeper tissues were anesthetized with 1% Xylocaine and a 14 gauge biopsy needle was advanced to the lesion through a small skin incision. 6 samples were obtained and sent to pathology in formalin. A linear, stoplight shaped metallic marker was left at the biopsy site. Hemostasis was achieved with several minutes of manual compression. The patient tolerated the procedure well.
Sample C left breast 1 oclock: The skin was prepped in the usual sterile fashion. The lesion at 1 oclock was located with direct ultrasound visualization. The skin and deeper tissues were anesthetized with 1% Xylocaine and a 14 gauge biopsy needle was advanced to the lesion through a small skin incision. 3 samples were obtained and sent to pathology in formalin. A ribbon shaped metallic marker was left at the biopsy site. Hemostasis was achieved with several minutes of manual compression. The patient tolerated the procedure well.
Sample D left breast 2 oclock: The skin was prepped in the usual sterile fashion. The lesion at 2 oclock was located with direct ultrasound visualization. The skin and deeper tissues were anesthetized with 1% Xylocaine and a 14 gauge biopsy needle was advanced to the lesion through a small skin incision. 6 samples were obtained and sent to pathology in formalin. A X shaped metallic marker was left at the biopsy site. Hemostasis was achieved with several minutes of manual compression. The patient tolerated the procedure well.
POST BIOPSY MAMMOGRAM: CC and ML views of the both breasts demonstrate for new biopsy markers. In the right breast, the stoplight shaped marker corresponds to sample A at 8 oclock. On the left, the stoplight shaped marker corresponds to biopsy site B at 3 oclock. The ribbon shaped marker at 1 oclock corresponds to biopsy site C in the X shaped biopsy marker at 2 oclock corresponds to biopsy site D. There is no significant post-biopsy hematoma at any of the biopsy sites.
IMPRESSION:
Uncomplicated bilateral breast ultrasound guided core biopsies. Pathology is pending.
EXAM:
MAMMOGRAM BILATERAL POST BIOPSY; ULTRASOUND GUIDED BREAST BIOPSY ADDITIONAL SITE; ULTRASOUND GUIDED BREAST BIOPSY BILATERAL
HISTORY:
Bilateral abnormalities identified on outside diagnostic MRI. Second-look ultrasound reveals multiple findings warranting further evaluation with ultrasound-guided core biopsy, detailed below.
PROCEDURE:
The details of the procedure were discussed with the patient and the risks, benefits and alternatives were explained. Her consent was documented.
Sample A right breast 8 oclock: The skin was prepped in the usual sterile fashion. The lesion at 8 oclock was located with direct ultrasound visualization. The skin and deeper tissues were anesthetized with 1% Xylocaine and a 14 gauge biopsy needle was advanced to the lesion through a small skin incision. 5 samples were obtained and sent to pathology in formalin. A linear, stoplight shaped metallic marker was left at the biopsy site. Hemostasis was achieved with several minutes of manual compression. The patient tolerated the procedure well.
Sample B palpable mass left breast 3 oclock: The skin was prepped in the usual sterile fashion. The lesion at 3 oclock was located with direct ultrasound visualization. The skin and deeper tissues were anesthetized with 1% Xylocaine and a 14 gauge biopsy needle was advanced to the lesion through a small skin incision. 6 samples were obtained and sent to pathology in formalin. A linear, stoplight shaped metallic marker was left at the biopsy site. Hemostasis was achieved with several minutes of manual compression. The patient tolerated the procedure well.
Sample C left breast 1 oclock: The skin was prepped in the usual sterile fashion. The lesion at 1 oclock was located with direct ultrasound visualization. The skin and deeper tissues were anesthetized with 1% Xylocaine and a 14 gauge biopsy needle was advanced to the lesion through a small skin incision. 3 samples were obtained and sent to pathology in formalin. A ribbon shaped metallic marker was left at the biopsy site. Hemostasis was achieved with several minutes of manual compression. The patient tolerated the procedure well.
Sample D left breast 2 oclock: The skin was prepped in the usual sterile fashion. The lesion at 2 oclock was located with direct ultrasound visualization. The skin and deeper tissues were anesthetized with 1% Xylocaine and a 14 gauge biopsy needle was advanced to the lesion through a small skin incision. 6 samples were obtained and sent to pathology in formalin. A X shaped metallic marker was left at the biopsy site. Hemostasis was achieved with several minutes of manual compression. The patient tolerated the procedure well.
POST BIOPSY MAMMOGRAM: CC and ML views of the both breasts demonstrate for new biopsy markers. In the right breast, the stoplight shaped marker corresponds to sample A at 8 oclock. On the left, the stoplight shaped marker corresponds to biopsy site B at 3 oclock. The ribbon shaped marker at 1 oclock corresponds to biopsy site C in the X shaped biopsy marker at 2 oclock corresponds to biopsy site D. There is no significant post-biopsy hematoma at any of the biopsy sites.
IMPRESSION:
Uncomplicated bilateral breast ultrasound guided core biopsies. Pathology is pending.