AHA Coding Clinic® for HCPCS - 2014 Issue 1; Ask the Editor

Percutaneous needle biopsy of vaginal cuff

What is the correct CPT code for a percutaneous core needle biopsy and fine needle aspiration (FNA) of the vaginal cuff? Both the FNA and core biopsy were performed at the same site percutaneously, not transvaginally. In addition, the pathology report mentions fibrofatty tissue. Since the documentation does not support CPT code 49180, Biopsy, abdominal or retroperitoneal mass, percutaneous needle, would the procedure be correctly reported with CPT code 20206, Biopsy, muscle, percutaneous needle? Or would CPT code 57100, Biopsy of vaginal mucosa; simple (separate procedure), be reported? ...

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