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Date: Feb 8, 2023


The skin site over the targeted lesions was prepped and draped. Lidocaine with infiltrated into the deeper tissues around the lesion. under direct sonographic guidance, aspiration was performed using a 22 gauge spinal needle. Lesion completely collapsed upon aspiration and approx. 2 cc of yellowish fluid was removed. A ring shaped biopsy marking clip was placed at the former site of the cyst.

Compression was held until hemostasis was achieved. The specimen was sent t the lab for analysis.

Post procedure digital CC and lateral mammograms were obtained which show resolution of the mammographic finding and the biopsy marking clip in the expected location

Impression: successful ultrasound-guided aspiration of 2cm cyst in the 4-5:00 position of the left breast.

Since this is a breast aspiration, would that clip placement be considered unlisted? I got codes 19000, 76942, 77065 but unsure of the clip placement. Thank you- DM

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