CPC Practice Exam 2

CPC Practice Exam 2 PRE OP DIAGNOSIS: Left Breast Abnormal MMG or Palpable Mass; Other Disorders of Breast PROCEDURE: Automated Stereotactic Biopsy Left Breast FINDINGS: Lesion is located in the lateral region, just at or below the level of the nipple on the 90 degree lateral view. There is a subglandular implant in place. I discussed the procedure with the patient today including risks, benefits and alternatives. Specifically discussed was the fact that the implant would be displaced out of the way during this biopsy procedure. Possibility of injury to the implant was discussed with the patient. Patient has signed the consent form and wishes to proceed with the biopsy. The patient was placed prone on the stereotactic table; the left breast was then imaged from the inferior approach. The lesion of interest is in the anterior portion of the breast away from the implant which was displaced back toward the chest wall. After imaging was obtained and stereotactic guidance used to target coordinates for the biopsy, the left breast was prepped with Betadine. 1% lidocaine was injected subcutaneously for local anesthetic. Additional lidocaine with epinephrine was then injected through the indwelling needle. The SenoRx needle was then placed into the area of interest. Under stereotactic guidance we obtained 9 core biopsy samples using vacuum and cutting technique. The specimen radiograph confirmed representative sample of calcification was removed. The tissue marking clip was deployed into the biopsy cavity successfully. This was confirmed by final stereotactic digital image and confirmed by post core biopsy mammogram left breast. The clip is visualized projecting over the lateral anterior left breast in satisfactory position. No obvious calcium is visible on the final post core biopsy image in the area of interest. The patient tolerated the procedure well. There were no apparent complications. The biopsy site was dressed with Steri-Strips, bandage and ice pack in the usual manner. The patient did receive written and verbal post-biopsy instructions. The patient left our department in good condition. IMPRESSION: 1. SUCCESSFUL STEREOTACTIC CORE BIOPSY OF LEFT BREAST CALCIFICATIONS. 2. SUCCESSFUL DEPLOYMENT OF THE TISSUE MARKING CLIP INTO THE BIOPSY CAVITY 3. PATIENT LEFT OUR DEPARTMENT IN GOOD CONDITION TODAY WITH POST-BIOPSY INSTRUCTIONS. 4. PATHOLOGY REPORT IS PENDING; AN ADDENDUM WILL BE ISSUED AFTER WE RECEIVE THE PATHOLOGY REPORT. What is (are) the CPT® code(s)? A. 19081 B. 19283 C. 19081, 19283 D. 19100, 19283 - To start narrowing your choices was the biopsy performed percutaneously or by an open incision? The operative note documents that a "SenoRx needle" was used to obtain the biopsy, which is percutaneous. Because there was a biopsy and a placement of a localization device (clip), you eliminate multiple choice B. Code 19283 is reported only for the placement of the localization device. Stereotactic image was used to perform the needle biopsy and placement of the clip. This eliminates multiple choice D, because code 19100 is for needle biopsy without imaging guidance. Code 19081 is the only code reported for the operative note because its code description reports both the biopsy and the placement of the clip under stereotactic imaging, eliminating multiple choice C. Answer A Question 2