tci General Surgery Coding Alert - 2021 Issue Q4

Reader Questions: Up the Ante on Bilateral Documentation

Question: Our provider performed a bilateral ultrasound (US)-guided fine needle aspiration (FNA) biopsy of the breasts. The operative report goes into full detail for aspiration of the right breast, but only indicates that “a similar procedure was performed on the left side.” Is this enough documentation to support a bilateral procedure? If so, how should I report the codes? Codify Subscriber Answer: This kind of verbiage is not unusual for a US-guided FNA biopsy report that indicates the surgeon performed a duplicate procedure contralaterally. Although the documentation you describe is not ideal, you shouldn’t need an...

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