Ask Dr. Z

I do not feel this documentation supports additional coding above the currently reported (19103LT, 76942, 19295LT, 77055) Understanding 76942 can only be reported once per encounter (NCCI Manual: Chapter 9, page 10); Do the biopsies obtained at the two "linear extensions" sites and current documentation support additional coding of 19103LT-59, 19103LT-59 and 19295LT-59, 19295LT-59? HISTORY: Lump in the left lower medial breast. Mammography and ultrasound show a highly suspicious mass, and biopsy was recommended. TECHNIQUE: The procedure of ultrasound-guided vacuum-assisted core needle biopsy was explained in detail including potential risks and complications such as bleeding and infection. Informed consent was obtained in writing. On the pre-biopsy scanning, I noted the bulk of the mass is accompanied by two somewhat linear extensions away from the larger body of the mass. I decided to biopsy all three areas and place clips in the two linear extensions for purpose of helping to guide the excision later. The skin and area around the mass were anesthetized with percutaneous injection of 9 cc of 1% buffered lidocaine. We then injected another 2 cc of lidocaine 1% with epinephrine into the deeper tissues for hemostasis. Once local anesthesia was achieved, a nick was made in the skin, and the Celera 12-gauge vacuum-assisted needle was advanced to the target labeled site 1, which is the bulk of the mass. We obtained three core samples in the usual way. Because this area is easily palpable, no clip was placed. We then reoriented the needle to the proximal slightly inferior projection, which was labeled site 2. Again, a 12-gauge sample was obtained under ultrasound visualization. We labeled this site with a CeleroMark clip. We then reoriented the needle towards a slightly more cephalad site labeled site 3, again using the 12-gauge vacuum assisted device, obtained one sample, and placed an Inrad clip in this area. Manual pressure was applied for hemostasis for about 10 minutes. We then obtained two-view mammography for assessment of the clip position. It shows both clips were deployed in the areas described adjacent to the bulk of the mass. Further manual pressure was applied for better hemostasis. A pressure bandage was applied, and post-biopsy instructions were given both verbally and in writing. The patient tolerated the procedure very well and left our office in excellent condition. CONCLUSION: Technically satisfactory ultrasound-guided vacuum-assisted core biopsy left 9 o'clock position, three sites were sampled. A total of five core specimens were obtained. Pathology is pending. Two small contiguous but slightly separate-appearing portions of the mass were sampled in addition to the larger aspect of the mass.