A Percutaneous-Image Guided Breast Biopsy Coding Case Study
Radiographic medical report
L. Breast Biopsy Needle Core
The above patient was seen at our office and the results of the examination are as follows:
Clinical History: Recent outside mammogram described an indeterminate group of microcalcifications in the medial aspect of the left breast, along the nine o'clock axis. Following consultation with Dr. Keith, a stereotactic biopsy was requested.
The risks, alternatives and benefits of the procedure were explained to the patient and written informed consent was obtained. Scout and stereotactic images of the left breast microcalcifications were obtained. The breast was prepped using Betadine. Following local anesthesia with approximately 5 cc of 1% Lidocaine, a small incision was made in the skin.
An 11-gauge mammotome was inserted through the incision to the level of the microcalcifications following the stereotactic coordinates. Stereotactic images were obtained to confirm accurate positioning of the mammotome probe. The mechanical cutter was then activated, tissue was cut, excised and transported through the mammotome probe to the collection chamber.
Specimen radiography following the first mammotomy sequence demonstrates the presence of the targeted microcalcifications within one of the tissue samples. Digital spot imaging of the biopsy site following the procedure demonstrates that the area of interest was satisfactorily sampled.
A Micromark sterile surgical clip was injected at the conclusion of the procedure to mark the biopsy site in the event of future surgical excision and to monitor future mammograms.
The individual tissue specimens were placed in Formalin in a sterile specimen container and sent to pathology for histological analysis.
Pressure was held on the biopsy site utilizing sterile 4 x 4 gauze until all bleeding subsided. The incision was closed with a Steri-Strip bandage.
The patient tolerated the procedure well without any immediate complications and was discharged with post biopsy instructions.
Thank you for the courtesy of this referral.
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