Breast Procedure
Breast procedure
Biopsy
Localization
Aspiration
Galactogram
Lymph -scintigraphy
Breast biopsy
It is a procedure in which part or all a suspicious breast growth is removed examined for cancer. Then the growth sample is suction out through a needle or cuts out.
Word used to refer to abnormal areas or growth before and after diagnosis may include lump mass lesions and tumors.
Core needle biopsy is a procedure where are a large needle with a cutting tip is used during core needle biopsy to draw a column of tissue out of the suspicious area.
Vacuum-assisted biopsy is a suction device to increase the amount of fluid and cells that is extracted through the needle.
Post Procedure Mammogram after insertion of clip and biopsy patient will have a unilateral mammogram. If the patient has stereotactic a breast biopsy then a post-biopsy mammogram can be taken in the biopsy table. Otherwise patient can be a move to the facility mammogram room to have regular mammography.
A post-procedure mammogram is a separate unilateral diagnostic study distinct and separate from stereotactic guidance which is performed to verify the clip deployment. If a mammogram is taken on the stereotactic table then it should not be coded separately.
Applying the guideline:-
The images facilities can code for a diagnostic mammogram following are stereotactic biopsy only if the patient is moved to a dedicated mammographic unit. If the exam is performed on the Sterioractic table you should not be coded separately. But the facility can report mammogram to perform following ultrasound-guided or MRI guided biopsy.
If the radiologist did not perform the service then he or she can report the code for interpreting the post-biopsy mammogram regardless of what modality the surgeon used for the biopsy.
How to code breast biopsy:-
You have to look for the following keyword in the report-
-Core or become assistant by biopsy
-breast clip placement for biomarker placement.
-guidance
-post-procedure mammogram
New Bundled Codes for Breast Biopsy With Image Guidance
New Bundled Codes for Breast Biopsy With Image Guidance
New Codes for Localization Device Placement
Breast localization /Needle localization /Wire localization/ Pre-op localization
It is performed to identify abnormal tissue in the breast for excision biopsy.
Breast cyst aspiration
A sterile needle was placed into the localized cyst with the subsequent aspiration of content.
Galactogram/Ductogram
It is performed by placing a small blunt needle into the dilated duct orifice in the nipple with an injection of a small amount of contrast followed by a mammogram obtain in CC and MLO angle of projection.
1. Sample Report:
DG MAMMO VAC BX W/CLIP
Indication- Left breast calcifications located at 12 -1 o'clock. Description- Written informed consent was obtained. The appropriate side was marked and a procedural pause was performed. The patient was positioned prone on the stereotactic table. The left breast was positioned for a craniocaudal approach. The initial scout radiograph showed the target. Stereo radiographs were used to determine the X, Y, and Z coordinates. The breast was cleansed sterilely. Lidocaine 1% was administered intradermally and in the parenchyma. A small incision was made. A 9 -gauge vacuum-assisted needle was passed percutaneously to the vicinity of the calcifications. The location of the needle was confirmed with additional stereo radiographs. Once appropriate positioning was confirmed, sampling was begun. Multiple specimens were obtained without difficulty. A specimen x-ray was performed and showed the calcifications to be present. A needle biopsy clip was deployed at the site. The needle was removed from the breast and manual compression was applied for about 10 minutes. There was prompt hemostasis. A post-procedure mammogram was performed and showed the clip in a good position.
Impression- Status post successful stereotactic vacuum-assisted needle Biopsy of microcalcifications in the left breast. There were no procedural complications and the patient was discharged in good condition. The results are pending at this time. This report will be addended once the pathology results are received.
2. Sample Report:
INDICATION- Left breast mass located at 8 o'clock.
Written informed consent was obtained. The patient was placed in the supine position. Preliminary scanning confirmed the previously identified mass. The breast was cleansed and draped sterilely. Lidocaine 1% was administered intradermally and within the parenchyma around the mass. A small incision was made. A 14-gauge core needle, attached to an automated spring-loaded biopsy gun device, was passed percutaneously under ultrasound guidance to the mass. Once the needle was was in position, several separate specimens were obtained without difficulty from different parts of the mass. These were submitted to pathology in formalin. The needle was removed from the breast. Manual compression was applied for about 5 minutes and there was prompt hemostasis. A biopsy marker clip was not placed due to the superficial position of this lesion. The dermatology was adequately dressed.
IMPRESSION- Status post successful core needle biopsy. The results are pending at this time. There were no procedural complications.
3. Sample Report:
INDICATION- DCIS.
TARGET- Biopsy marker
The procedure was explained to the patient. The patient was positioned seated in front of a standard upright mammogram machine. The right breast was positioned for a superior approach. The initial scout radiograph showed the target. The area was cleansed sterilely. Lidocaine 1% was administered intradermally. A 5 cm localizing needle was passed percutaneously to the vicinity of the target. Once the needle's position was confirmed by orthogonal views, a hook wire was placed through the needle and the needle was removed. Final post localization mammography showed the hook wire immediately adjacent to the target. A single specimen was submitted for radiography. It shows the hook wire and biopsy marker
IMPRESSION- Status post successful localization with positive specimen radiography.
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