Breast Cyst Aspiration

Summer 2024 pages 4-8 CLINICAL EXAMPLE 1: Breast Cyst Aspiration CLINICAL INDICATION A 52-year-old female with an acutely painful left breast cyst PROCEDURE Aspiration of a left breast cyst with ultrasound guidance TECHNIQUE Informed written consent, including a discussion of the risks, benefits, and alternatives to the procedure, was obtained from the patient. A standard time-out was performed. The patient was prepared and draped in standard fashion. Using ultrasound guidance and lidocaine local anesthesia, the left breast cyst at the 2 o'clock position at 5 cm from the nipple was aspirated using a 20-gauge needle. After confirmation that the needle...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article presents a breast cyst aspiration example and discusses the associated coding references from CPT, ICD-10-CM, and Medicare/NCCI guidance. It is intended for coding professionals, radiology staff, and reimbursement teams who need to understand the general scope of reporting considerations for this type of procedure. The content also notes related guidance sources and the broader context of imaging supervision, bilateral reporting, and payer policy references.

Why This Topic Matters

Breast cyst aspiration can involve more than one code family and may be affected by imaging guidance and payer policy references. Understanding the article helps coders determine whether the full discussion is relevant to radiology procedure reporting and supporting documentation review.

Article Sections

  1. Summer 2024 pages 4-8

    A short publication header identifying the issue and page range for the case example.

  2. Clinical Example 1: Breast Cyst Aspiration

    A procedural case example describing the clinical scenario, imaging-assisted procedure, and post-procedure outcome at a high level.

  3. How to Code

    A coding-focused section that lists the relevant code families and summarizes the surrounding guidance topics without detailing selection logic.

  4. Discussion

    Broader commentary on radiology reporting considerations, payer policy references, and related guidance sources for the procedure type.

  5. Sources

    A bibliography of professional society and Medicare policy references used in the article.

What You Will Learn

  • The general clinical context for breast cyst aspiration.
  • Which coding systems are discussed in the article.
  • What kinds of imaging guidance and payer-policy topics are addressed.
  • How the article is organized around a clinical example and discussion section.

Who Should Read This

  • Medical coders
  • Radiology coding specialists
  • Compliance staff
  • Revenue cycle professionals
  • Radiology departments

Codes Discussed

Code Ranges Discussed

  • CPT: 76942, 77002, 77003, 77012, AND 77021

Modifiers Discussed


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