AMA Clinical Examples in Radiology - 2005 Issue 3 (Summer)
Ultrasound-Guided Breast Biopsy, Needle Core
Ultrasound-Guided Breast Biopsy, Needle Core Clinical History Upper-outer right breast lesion. Previous sonographic evaluation of the right breast was performed, which demonstrated a hypoechoic slightly lobulated ovoid lesion at about the 10 o'clock position, 8 to 9 cm from the nipple, measuring about 20 × 9 × 22 mm in size. It is surrounded by echogenic breast tissue. Technique Risks and benefits were described to the patient. Risks discussed included inadequate sampling, bleeding, and possible need for further testing. Consent was signed. Preliminary ultrasound confirms the previously described lesion to be present and unchanged. Skin surface inferior to the...
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Article Overview
This article reviews a radiology coding scenario involving a breast biopsy performed with ultrasound guidance. It is aimed at coders, billers, and radiology staff who need to identify the relevant procedure category, associated imaging services, and related documentation considerations discussed in the example and commentary.
Why This Topic Matters
Breast biopsy coding often depends on procedure approach, imaging support, and whether additional related services are separately reportable. This article helps readers understand the scope of guidance discussed in a common radiology biopsy example.
Article Sections
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Clinical History
Describes the clinical context and lesion location that led to the procedure.
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Technique
Summarizes how the biopsy procedure was performed and the general workflow documented in the example.
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Impression
Provides the procedure outcome and follow-up context from the radiology report.
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How to Code
Lists the primary procedure coding assignment discussed for the example.
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Discussion
Explains broader coding context for breast biopsy reporting, including associated imaging, related procedures, and documentation topics.
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Coding Tips
Reviews additional related breast procedure codes, imaging guidance references, and reporting considerations mentioned by the source.
What You Will Learn
- How this breast biopsy scenario is framed for coding purposes
- What related imaging and ancillary services are discussed
- Which general documentation and reporting topics are highlighted
- How the article situates the example within broader breast biopsy coding guidance
Who Should Read This
- Medical coders
- Radiology coders
- Billing staff
- Radiology practices
- Compliance reviewers
Codes Discussed
Modifiers Discussed
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