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General Surgery Coding Alert

Breast Case:
Capture Each Step of 2-Phase Case to Boost Breast Surgery Pay

Distinguish lesion excision, lumpectomy. When a patient advances through multiple diagnostic and treatment steps for breast cancer, your surgeon might perform several procedures -- and you might face bundling issues that limit your billing opportunities. Let our experts lead you through one case in point - from initial patient complaint to definitive diagnosis -- so you can learn how to capture all the pay your surgeon deserves. Phase 1: Needle Specimens for Diagnosis Scenario: Based on mammogram findings of a lump in her right breast (upper inner quadrant), a patient presents to your surgeon's suite for an ordered fine needle aspiration (FNA). "Physicians often use FNA to obtain cellular specimens from a breast mass for diagnosis," says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. For the FNA procedure, the surgeon inserts a thin needle into the breast mass and uses the syringe to extract cells, which he sends [...]