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CT guided aspiration pelvic cystic mass

Date: Dec 1, 2023

Question:

"Localized prone CT scans were obtained through the left pelvic cystic mass in suitable left transgluteal entry site was selected, marked and prepped and draped in the usual sterile fashion. 1% lidocaine was administered and stab incision made with a #11 blade. Utilizing intermittent CT fluoroscopy, a 5 French centesis catheter was advanced into the mass with 20 cc of serous fluid aspirated, sent for cytology, as requested. There were no adverse incidence.

IMPRESSION: CT-guided aspiration of left cystic pelvic mass."

Would this be coded with 49180 or 10160? Diagnosis reported for biopsy would be the pre-procedure diagnosis or the post-procedure diagnosis per the pathology report?

Question ID : 19683
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