Mary Flo Ankeny, BPS, CPC, RCCWith assistance from C. Marie Zinck , CPC,

RCC

Starting with the basicsMammogram –screening 77057Mammogram – diagnostic 77056Mammogram – unilateral 77055Computer Assisted Detection (CAD) screening 77052Computer Assisted Detection (CAD) diagnostic

77051Digital Mammography – screening G0202Digital Mammography – diagnostic G0204Digital Mammography – unilateral Go206GG modifer GH modiferUltrasound – unilateral limited 76642Ultrasound – unilateral complete (4 quad) unilateral

76641

Starting with the basics continuedMagnetic Resonance Imaging Breast Unilateral 77058Magnetic Resonance Imaging Breast Bilateral 77059MRI Guidance 77021MRI CAD 0159TGadolinium A7695Pro-Hance A9576Scintimammography 78800Sestabibi A9500Aspiration 19000 & 19001Wire Localitization w/ MRI guidance 19287 (+19288)Wire Localization w/Mammographic guidance 19281

(+19282)

Stereotatic Breast BiopsyStereotatic – guidance for the biopsy 77031Percutaneous breast biopsy 19102Vacuum-assisted breast biopsy 19103Clip placement 19295Specimen x-ray 76098Unilateral Mammogram w/CAD G0206 & 77051Bilateral Mammogram w/CAD G0204 & 77051

CODES REPLACED

CODES R

EPLACED

COMBINED

C

OMBINED

Stereotatic Breast Biopsy beginning 2014

•19081 “Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the specimen, when performed, percutaneous; first lesion, including stereotactic guidance”

•+19082 “each additional lesion, including stereotatic guidance (list separately in addition to code primary procedure) cpt book by AMA

Stereotactic Breast Biopsy ReportStereotactic Large Core Left Breast Biopsy

And Digital Diagnostic Unilateral Left Mammogram With Cad

Findings: Technique: the management of this patient’s nonpalpable mammographic abnormality was discussed prior to the procedure. The risk and benefits of the stereotactic biopsy were explained to the patient. All questions were answered. The patient understood and agreed to proceed.

Stereotactic Breast Bx Report cont.The left breast was compressed in a usual fashion and approached

from a lateral to medial approach. The skin was prepped with Betadine and anesthetized with 1% Xylocaine. A small skin incision was made. Through this incision, a Hologic Eviva 9 – gauge vacuum-assisted biopsy device was fired into the breast and noted to be in accurate position on digital radiographs. After additional administration of a mixture of Lidocaine and Epinephrine, multiple large core vacuum assisted biopsies were obtained. There were no immediate complications.

A specimen radiograph demonstrated satisfactory removal of calcifications.

A stainless steel microchip was left in place at the biopsy site.Post biopsy mammogram demonstrates appropriate clip placement.

Patient tolerated the procedure well. Pathology results are pending.IMPRESSION: SUCCESSFUL STEREOTATIC LEFT BREAST BIOPSY.UNREMARKABLE POST BIOPSY MAMMOGRAM AS ABOVE.

Ultrasound Guided Breast Biopsy Ultrasound Guidance 76042Percutaneous core sample 19102Percutaneous Vacuum-Assisted 19103Clip placement 19295Mammogram w/CAD – unilateral G0206 &

77051Mammogram w/CAD – Bilateral G0204 &

77051 codes combined into one

Ultrasound Guided Breast Biopsy Beginning 2014

•19083 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the specimen, when performed, percutaneous; first lesion, including ultrasound guidance”

•+19084 each additional lesion, including ultrasound guidance (list separately in addition to code primary procedure) cpt book 2015

Ultrasound Breast Biopsy ReportULTRASOUND LT BREAST BIOPSY MULTIPLE SITES, DIGITAL DIAGNOSTIC LT MAMMO WITH CAD

COMPARISON:Diagnostic mammogram and ultrasound 4/13/2015

CLINICAL HISTORY:Probable solid lump left breast 12:00 position and adjacent small solid noduleat the 10:00 position

PROCEDUREConsent was obtained for ultrasound guided left breast biopsy. The larger noduleleft breast is located at the 12:00 position. The smaller nodule at the 10:00position measures 1 cm. The skin was prepped with Betadine and anesthetized.Under ultrasound guidance a 13-gauge needle guide was advanced into the breastand multiple cores were obtained with a 14-gauge long throw biopsy and at eachsite. A microclip was left in place at the smaller nodule site.

A unilateral left mammogram was obtained and demonstrates a microclip in theleft upper inner breast.

The patient tolerated the procedure well.

IMPRESSION:ULTRASOUND GUIDED BIOPSY OF 2 SOLID NODULES IN THE LEFT BREAST

MRI Guided Breast Biopsy ReportMRI GUIDED LEFT BREAST BIOPSY WITHOUT AND WITH CONTRAST AND DIGITAL DIAGNOSTIC LEFT UNILATERAL MAMMOGRAM

WITH CAD

CLINICAL HISTORY:Enhancing lesion in the mid left lateral breast, approximately 3 o'clock position.

FINDINGS:Risks and benefits were explained to the patient and informed consent was obtained.

Using a dedicated breast coil with gentle breast compression, the following sequences of the left breast were obtained: Sagittal T1 weighted localization sequence and a 3-D dynamic sequence using a 3-D Vibrant fat suppressed T1 weighted image pre and post bolus intravenous injection of a standard dose of Gadolinium using a power injector. The standard and dynamic images of the breasts were reviewed on a dedicated DynaCAD interventional workstation. 3-D rendering was utilized for image evaluation and biopsy planning.

The lesion in question was redemonstrated in the left anterior to mid lateral breast. The skin was prepped with Betadine and anesthetized with lidocaine. The vacuum-assisted 9-gauge biopsy device was inserted into the breast from a lateral approach. MR images confirmed appropriate positioning of the guiding needle. Approximately 12 core samples were obtained and a microclip was placed at the site. Follow up MR imaging as well as mammographic imaging of the left breast demonstrates deployment of the clip, although it is noted to be slightly shallow to the biopsied lesion by approximately 8 mm. Pathology results are pending.

IMPRESSION:SUCCESSFUL LEFT BREAST MRI-GUIDED BIOPSY OF A SMALL ENHANCING LESION IN THE APPROXIMATELY 3 O'CLOCK POSITION

OF THE LEFT BREAST. PATHOLOGY RESULTS PENDING.

Breast Aspiration19000 – “Puncture aspiration of cyst of

breast+19001 – “each additional cyst…)76942 - ultrasound guidance77021 - Mammographic guidance

Breast Aspiration ReportULTRASOUND GUIDED RIGHT BREAST ASPIRATION

CLINICAL HISTORY:Postbiopsy hematoma.

FINDINGS:During site check from right breast stereotactic biopsy, the biopsy site remains enlarged with a focal palpable area. Ultrasound imaging was performed to assess for possible abscess collection.

Ultrasound imaging demonstrated the presence of a focal fluid collection with some internal echoes measuring approximately 2.2 x 1.4 x 2.5 cm. There is no associated vascularity associated with this. The wall does not appear significantly thick.

The findings were reviewed with the patient. Aspiration of this fluid was then performed. The skin was prepped and draped in sterile fashion and local lidocaine anesthetic was administered. An 18-gauge needle was used to aspirate the collection. The fluid was dark reddish brown and slightly thick, most consistent with blood products. The collection was able to be almost completely aspirated. Approximately 5.5 mL was removed.

The patient tolerated the procedure well. Specimen was sent for gram stain, culture and sensitivity.

IMPRESSION:ULTRASOUND-GUIDED ASPIRATION OF A POSTBIOPSY FLUID COLLECTION WAS PERFORMED IN THE RIGHT BREAST. THE COLLECTION LIKELY REPRESENTS RESOLVING HEMATOMA. SPECIMEN WAS SENT FOR TESTING FOR INFECTION. RESULTS ARE PENDING.

Mammography Guided Wire Localization

Mammography Guided Breast Wire Localization Report

MAMMOGRAPHY GUIDED LEFT BREAST WIRE LOCALIZATION, SPECIMEN RADIOGRAPH, DIGITAL DIAGNOSTIC LEFT UNILATERAL MAMMOGRAM WITH CAD

COMPARISON:April 20 2/15/1930 back to February 2013

CLINICAL HISTORY:Invasive ductal carcinoma left breast in the 1:30 position upper outer quadrant, nodule previously biopsied by ultrasound

History of fibroadenoma 3:00 position anterior left breast.

TECHNIQUE: Were asked to localize both the 1:30 and 3:00 lesions with needle localization.

FINDINGS: With patient in lateral medial compression, using a alphanumeric grid, a 5 cm Kopan's needle was placed into the left breast from lateral to medial approach at site of nodule which was positive for malignancy and clip in the 1:30 position. Position confirmed with orthogonal views and the wire was deployed and is seen in excellent position post placement. This site at site of patient's invasive cancer was labeled SITE A. A single marker clip marking previous biopsy nodule is present at site A.

Next the 2 microclip's and fibroadenoma in the 3:00 position left breast was localized using the exact same technique with a 7 cm Kopans needle. The wire was deployed and this site was labeled SITE B. The patient was then sent to nuclear medicine for sentinel lymph node localization injection.

2 specimen radiographs were performed. SITE A includes the wire, nodule and clip. SITE B includes the nodule and 2 clips as well as wire. Findings consistent with successful excision of both sites.

IMPRESSION:SUCCESSFUL NEEDLE LOCALIZATION AND EXCISION OF 2 SITES LEFT BREAST. TISSUE SENT FOR PATHOLOGIC EVALUATION.

SITE A REPRESENT SITE OF CANCER. A SINGLE MICROCLIP IS PRESENT. SITE B REPRESENT SITE OF FIBROADENOMA WITH 2 MICROCLIPS PRESENT

MRI Guided Wire Localization

•19287 – “Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including magnetic resonance guidance.”•19288– “each additional lesion, including magnetic resonance guidance”•76098 - “Radiological examination, surgical specimen• CPT 4 2015 AMA

MRI Guided Breast Wire Localization Report

MRI LOCALIZATION OF THE LEFT BREAST AND DIGITAL DIAGNOSTIC UNILATERAL LEFT MAMMOGRAM WITH CAD

TECHNIQUE AND FINDINGS:Multiple sequences were obtained without and with gadolinium contrast in order to localize the previously biopsied lesion and clip.

The procedure was explained to the patient and informed consent was obtained. The previously biopsied lesion demonstrates minimal enhancement at this time. Much of it was likely removed during initial sampling. However, a small area is identified for targeting. Using a lateral approach, the skin was prepped with Betadine and anesthetized with Lidocaine. A MRI localizing wire and needle was inserted and the wire was deployed after appropriate position was confirmed with MRI images.

Mammographic images were also obtained demonstrating the wire to be in appropriate position, demonstrating the clip and biopsy changes along the course of the wire.

The patient was sent for lumpectomy and sentinel node biopsy.

IMPRESSION:SEE ABOVE.

Specimen Report after Localization

SPECIMEN RADIOGRAPH

FINDINGS:Left breast specimen radiograph demonstrates successful excision of the localizing wires, clip as well as some focal density along the wire.

Pathology results pending.

NUCLEAR MEDICINE LYMPH PRESURGERY INJECTION

•38792 – “Injection procedure; lymphangiography, radioactive tracer for identification of sentinel node”•78195 – “Lymphatics and lymph nodes imaging•A9520 - Radionuclide used in exam (eg technetium-99m labeled tilmanocept) CPT 4 2015 AMA

NUCLEAR MEDICINE LYMPH PRESURGERY INJECTION

FINDINGS:The skin was prepped with alcohol and a skin surface numbing agent was applied. Four aliquots totalling approximately 500 uCi of technetium-99m labeled tilmanocept was injected intradermally around the areola at 12, 3, 6 and 9 o'clock positions. The patient was then sent for surgery at IRSC.

IMPRESSION:SEE ABOVE.

Nuclear Medicine Lymphoscintigrapy Report

Injection Only

NUCLEAR MEDICINE LYMPH PRESURGERY INJECTION AND MAPPING

COMPARISON:None.

CLINICAL HISTORY:Left breast DCIS

TECHNIQUE: 500 uCi of technetium 99m Tilmanocept used.

FINDINGS: The left breast periareolar region was prepped with alcohol.4. Aliquots of radiotracer were injected intradermally in the left outer breastperiareolar region.

Scintigraphic imaging was performed. A single sentinel lymph node was identifiedby scintigraphic imaging. The skin was marked over this region. The patient wasthen sent for sentinel node biopsy.

IMPRESSION:SUCCESSFUL LYMPHOSCINTIGRAPHY AS ABOVE.

Nuclear Medicine LYMPH Presurgery Injection and Mapping Report

ReferencesAbout.com Breast CancerRadiology Info. OrgAMA cpt 2011AMA cpt 2015