Using the coding techniques described in this chapter, carefully read through the case study and determine the most accurate CPT code(s) and HCPCS code(s) and modifier(s), if appropriate. PROCEDURE: Needle-localized biopsy, right breast DESCRIPTION OF PROCEDURE: After proper consent was obtained, the patient (48-year-old female) was brought to the operating room and placed on the table in a supine position. Patient was given 2 mg of midazolam HCL, IV, titrated during the procedure; the nurse monitored Davida’s vital signs for a total of 15 minutes. The right breast area was prepped and draped in a sterile manner. Plain Marcaine 0.5% solution was injected for local anesthesia in the perioperative region. A curvilinear incision was made medial to the insertion site of the wire, as the wire
Using the coding techniques described in this chapter, carefully read through the case study and determine the most accurate CPT code(s) and HCPCS code(s) and modifier(s), if appropriate.
PROCEDURE: Needle-localized biopsy, right breast
DESCRIPTION OF PROCEDURE: After proper consent was obtained, the patient (48-year-old female) was brought to the operating room and placed on the table in a supine position. Patient was given 2 mg of midazolam HCL, IV, titrated during the procedure; the nurse monitored Davida’s vital signs for a total of 15 minutes.
The right breast area was prepped and draped in a sterile manner. Plain Marcaine 0.5% solution was injected for local anesthesia in the perioperative region. A curvilinear incision was made medial to the insertion site of the wire, as the wire was noted to pass medially in the breast. The preoperative localization films were reviewed, noting that the clip was posterior to the wire. The dissection was carried out with cautery to remove a core of tissue around the wire, being more generous on the posterior aspect around the wire and especially near the end of the wire, taking a very generous area of tissue posteriorly; in fact, it was all the way down to the pectoralis fascia at that site. The specimen was removed, noting that the wire was within the mid portion of removed tissue with a large amount of surrounding tissue. This was submitted for radiographic analysis and the wire was noted to be within the large specimen. However, the clip could not be visualized. For this reason, the operative area was inspected with fluoroscopy with diligence and there was no evidence of any residual clip within the right breast tissue or within the drapes around the right breast. The Ray-Tec sponge was also evaluated with fluoroscopy and direct inspection and no clip was noted. The suction canister and tubing were also evaluated with fluoroscopy and no clip was noted. At this point, due to the generous size of the biopsy specimen, decision was made to not blindly remove any further breast tissue. I suspect that the clip may have become stuck to a Ray-Tec sponge or other instrument during this procedure and came out of the wound and fell out of the field of dissection. The operative area was irrigated, noted to hemostatic, and closed in layers using interrupted #3-0 Vicryl suture to close deep dermis and running #4-0 subcuticular Vicryl suture to close the skin. Benzoin, Steri-Strips, and sterile gauze dressings were placed. The patient had her sedation stopped and she was taken to the recovery area.
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