tci General Surgery Coding Alert - 2020 Issue Q4

You Be the Coder: Get Details for Cyst Fluid Specimen Case

Question: Our surgeon obtained a sample of fluid from an ovarian cyst under ultrasound guidance for a patient to rule out ovarian cancer. How should we code the procedure? Nevada Subscriber Answer: You don’t provide enough information to accurately assign a surgical code. You’ll have to confirm the method the surgeon used to collect the specimen before you can choose the correct code. The main question is whether the surgeon was draining the cyst as treatment, or taking a sample, such as a fine needle aspiration (FNA), for diagnostic purposes. The answer will direct you to different...

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