tci Outpatient Facility Coding Alert - 2012 Issue 1

You Be the Coder: Separating 19000 From 10021

Question: One of our surgeons documented, "Cyst aspiration ... clear yellow serous fluid was removed from the left breast cyst ... send the specimen for cytology with strong family hx of breast cancer." The pathology report reads, "Surgical procedure reads: specimens: a fine needle aspiration of left breast cyst." Should we report code 19000 or 10021?Florida SubscriberAnswer: The correct choice is 10021 (Fine needle aspiration; without imaging guidance). Explanation: Fine needle aspiration is a diagnostic procedure that involves collecting an "aspirate" (a small amount of cells, tissue, or fluid) from a cyst or mass. Because no imaging guidance...

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