Ask Dr. Z

How would an ultrasound-guided biopsy of a reconstructed breast be coded? Is this considered breast tissue, or would we use codes 20206 and 76942?

INDICATION: HISTORY OF BILATERAL MASTECTOMIES FOR LEFT BREAST CANCER IN 2022. NOW WITH REGION OF PALPABLE CONCERN IN THE RECONSTRUCTED LEFT BREAST. THE BREAST WAS STERILELY PREPPED AND DRAPED AND LOCAL ANESTHESIA WAS PRODUCED WITH 7 ML 1% BUFFERED LIDOCAINE. UNDER ULTRASOUND GUIDANCE, A 13 GAUGE TROCHAR WAS ADVANCED TO THE LESION AND A 14 GAUGE SPRING-LOADED BIOPSY NEEDLE WAS USED TO OBTAIN 4 CORE SAMPLES THROUGH THE LARGER OF THE HYPOECHOIC OVAL MASSES LOCATED AT 10:00, 3 CM FROM THE NIPPLE IN THE LEFT BREAST. TISSUE CORES WERE PLACED IN FORMALIN AND SENT TO PATHOLOGY.

IMPRESSION: SUCCESSFUL ULTRASOUND-GUIDED CORE BIOPSY OF LEFT BREAST MASS.