Author Topic: Breast Bx and Aspiration  (Read 2818 times)

TxJFP

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Breast Bx and Aspiration
« on: February 13, 2012, 11:09:03 PM »
Hello Everyone,

I am working on a couple of procedures for a hospital, Outpatient Setting, and came across a breast bx as well as aspiration. Now after reading the op report, it does state Aspiration initially and then went in on other lesions doing a Bx.

Here's a brief view of op report:

Loc Anesthesia
(2) cysts identified @ 6 o'clock position
@ 530 position is a more solid mass

The (2) cysts in 6 o'clock position were aspirated w/fluid obtained and given to pathology for cytology. A marker was placed between the (2) cysts.

Next:

The more solid mass @ the 530 position was biopsied w/14 gauge vacuum assisted Bx needle times (2). The lesion appeared to collapse and therefore it is felt that this most likely represented a complex cyst. (2) specimens were given to pathology for further evaluation study. A marker was placed.

IMP:

U/S guided breast aspiration and Bx as above.

In my opinion, I would go on and do separate CPT codes since the Dr specifically states the vacuum assisted gauge during the Bx. However, the aspiration does not give a needle measurement nor does it state FNA (fine needle aspiration). I feel I could go with CPT code 19000 (puncture aspiration of cyst of breast). 19103 and 19295 (Breast Bx with vacuum assisted and metallic clip). Inputting modifier -59 with the puncture aspiration...?

OH and since it states above that the needle Bx was done times, that would have to be coded twice, or would this have to queried to the physician to clarify if the Bx was actually done twice on the same breast and lesion.

If someone has come across something similar, could you please put in your suggestions? :)

koatsj

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Re: Breast Bx and Aspiration
« Reply #1 on: February 14, 2012, 09:45:51 AM »
Well, I would bill 19000 and use -RT or -LT to specify which breast and then use 19001 billed the same way as the doctor does state he aspirated two cysts. I would then bill for the vacuum-assisted biopsy as well.  ;D