PREOPERATIVE DIAGNOSIS:
1. Metastatic carcinoma paravertebral region left side.
2. Personal history of hepatocellular carcinoma.
3. Status post microwave ablation.
4. Personal history of renal cell carcinoma.
POSTOPERATIVE DIAGNOSIS:
1. Metastatic carcinoma paravertebral region left side.
2. Personal history of hepatocellular carcinoma.
3. Status post microwave ablation.
4. Personal history of renal cell carcinoma.
PROCEDURE PERFORMED:
Ultrasound-guided percutaneous needle biopsy of left paravertebral
mass.
SURGEON:
X
FIRST ASSISTANT:
X
SECOND ASSISTANT:
X
ANESTHESIA:
Local infiltrated with 0.5 percent lidocaine with epinephrine. The
patient also received intravenous sedation.
ATTENDING ANESTHESIOLOGIST:
X
ESTIMATED BLOOD LOSS:
None.
COMPLICATIONS:
None.
JUSTIFICATION FOR THE PROCEDURE:
Mr. X is a 62-year-old male with a personal history of renal cell
carcinoma status post left nephrectomy and status post microwave
ablation of hepatocellular carcinoma. The patient had the diagnosis
of status cell carcinoma established on 09/02/2012 and on 10/02/2012
underwent a microwave ablation. On restaging studies, the patient was
found to have a new mass in the in the paravertebral region on the
left side between the T12 and L1. The patient is now complaining of
back pain. In addition, the liver shows progressive malignant disease
and at this point, the patient comes to the operating room to have a
histologic diagnosis established. There is clinical concern that the
patient may now have metastatic renal cell carcinoma as opposed to
progressive and metastatic hepatocellular carcinoma. Before final
recommendation is made for additional therapy, the patient will have a
histologic diagnosis established today.
INFORMED CONSENT:
In the holding area, before the patient was brought into the operating
room, he signed an informed written consent. I had explained to him in
detail the purpose of the procedure and the risks associated with the
surgery. The risks that I explained to the patient included bleeding
and puncture of adjacent organs.
PATIENT IDENTIFICATION:
In the operating room, before the procedure was started, we took a
"time-out" to properly identify the patient by name, as well as
intended surgical procedure. Once the nurse anesthetist and the
circulating nurse agreed with the proper identification of the patient
and the intended surgical procedure, the operation was started as
described below.
PROCEDURE IN DETAIL:
The patient was placed supine in the operating table and after
satisfactory intravenous sedation, he was placed on the lateral
decubital position with the left side up. The posterior trunk was
prepared sterile with DuraPrep solution and draped sterilely. The skin
was infiltrated with 0.5 percent Marcaine and then using the handheld
Aloka ProSound 5 ultrasound, the mass was identified and used for
guidance of Tru-Cut needle. The skin was incised with a number 15
blade and then the Tru-Cut needle was used to obtain four cores of the
tissue. Two of those cores were sent to pathology for frozen section
and two of them were sent to pathology for permanent section
examination. By frozen section, the pathologist was able to
established the diagnosis of malignancy. The final diagnosis whether
this is hepatocellular carcinoma or renal cell carcinoma will be
deferred for the permanent section when immunohistochemistry studies
can be performed on the tissue.
Once the biopsies were obtained, pressure was held in the area until
hemostasis was completely achieved. The incision then was sealed with
Octylseal. At the end the procedure, the patient was transferred back
to the recovery room, breathing spontaneously with normal stable vital
signs.
-----------------------------------------------------------------------------------
This is for Physician Practice Coding , I have Coded as follow :
20206
76942,26
Please advice if it ok or someone comes up with a different CPT code.
Thank you in advance !!!
1. Metastatic carcinoma paravertebral region left side.
2. Personal history of hepatocellular carcinoma.
3. Status post microwave ablation.
4. Personal history of renal cell carcinoma.
POSTOPERATIVE DIAGNOSIS:
1. Metastatic carcinoma paravertebral region left side.
2. Personal history of hepatocellular carcinoma.
3. Status post microwave ablation.
4. Personal history of renal cell carcinoma.
PROCEDURE PERFORMED:
Ultrasound-guided percutaneous needle biopsy of left paravertebral
mass.
SURGEON:
X
FIRST ASSISTANT:
X
SECOND ASSISTANT:
X
ANESTHESIA:
Local infiltrated with 0.5 percent lidocaine with epinephrine. The
patient also received intravenous sedation.
ATTENDING ANESTHESIOLOGIST:
X
ESTIMATED BLOOD LOSS:
None.
COMPLICATIONS:
None.
JUSTIFICATION FOR THE PROCEDURE:
Mr. X is a 62-year-old male with a personal history of renal cell
carcinoma status post left nephrectomy and status post microwave
ablation of hepatocellular carcinoma. The patient had the diagnosis
of status cell carcinoma established on 09/02/2012 and on 10/02/2012
underwent a microwave ablation. On restaging studies, the patient was
found to have a new mass in the in the paravertebral region on the
left side between the T12 and L1. The patient is now complaining of
back pain. In addition, the liver shows progressive malignant disease
and at this point, the patient comes to the operating room to have a
histologic diagnosis established. There is clinical concern that the
patient may now have metastatic renal cell carcinoma as opposed to
progressive and metastatic hepatocellular carcinoma. Before final
recommendation is made for additional therapy, the patient will have a
histologic diagnosis established today.
INFORMED CONSENT:
In the holding area, before the patient was brought into the operating
room, he signed an informed written consent. I had explained to him in
detail the purpose of the procedure and the risks associated with the
surgery. The risks that I explained to the patient included bleeding
and puncture of adjacent organs.
PATIENT IDENTIFICATION:
In the operating room, before the procedure was started, we took a
"time-out" to properly identify the patient by name, as well as
intended surgical procedure. Once the nurse anesthetist and the
circulating nurse agreed with the proper identification of the patient
and the intended surgical procedure, the operation was started as
described below.
PROCEDURE IN DETAIL:
The patient was placed supine in the operating table and after
satisfactory intravenous sedation, he was placed on the lateral
decubital position with the left side up. The posterior trunk was
prepared sterile with DuraPrep solution and draped sterilely. The skin
was infiltrated with 0.5 percent Marcaine and then using the handheld
Aloka ProSound 5 ultrasound, the mass was identified and used for
guidance of Tru-Cut needle. The skin was incised with a number 15
blade and then the Tru-Cut needle was used to obtain four cores of the
tissue. Two of those cores were sent to pathology for frozen section
and two of them were sent to pathology for permanent section
examination. By frozen section, the pathologist was able to
established the diagnosis of malignancy. The final diagnosis whether
this is hepatocellular carcinoma or renal cell carcinoma will be
deferred for the permanent section when immunohistochemistry studies
can be performed on the tissue.
Once the biopsies were obtained, pressure was held in the area until
hemostasis was completely achieved. The incision then was sealed with
Octylseal. At the end the procedure, the patient was transferred back
to the recovery room, breathing spontaneously with normal stable vital
signs.
-----------------------------------------------------------------------------------
This is for Physician Practice Coding , I have Coded as follow :
20206
76942,26
Please advice if it ok or someone comes up with a different CPT code.
Thank you in advance !!!