When a patient advances through multiple diagnostic and treatment steps for breast cancer, your surgeon might perform several procedures—and you might face bundling issues that limit your billing opportunities.
Follow our experts’ advice through one case in point— from initial patient complaint to definitive diagnosis —so you can learn how to capture all the pay your surgeon deserves.
|General Surgery Coding AlertFrom complex op notes fraught with bundling issues to unlisted lap surgical procedures that thwart your best coding instincts, let the experts at General Surgery Coding Alert lead you through the coding landmines to better pay on the other side. Click here to buy.|
Phase 1: Needle Specimens for Diagnosis
Scenario: Based on mammogram findings of a lump in her right breast (upper inner quadrant), a patient presents to your surgeon’s suite for an ordered fine needle aspiration (FNA). “Physicians often use FNA to obtain cellular specimens from a breast mass for diagnosis,” says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.
For the FNA procedure, the surgeon inserts a thin needle into the breast mass and uses the syringe to extract cells, which he sends to pathology for immediate evaluation for adequacy. Based on the report that the specimen is inadequate for diagnosis, the surgeon performs a second FNA of the same lesion, this time under radiologic guidance. The specimen again returns inadequate for diagnosis. The surgeon consults with the pathologist, who recommends a percutaneous needle core biopsy (PNB) of the lesion due to cellular artifacts.
The surgeon proceeds to perform a PNB of the lesion with imaging guidance, using a larger-bore needle to remove a “core” tissue sample from the lesion. The surgeon...
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