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Ob-Gyn Coding Alert

Reader Question:

Consider 10021 for FNA Without U/S

Question: My ob-gyn performed the following procedure: Office pelvic ultrasound revealed solid and cystic components. Verbal consent obtained prior to procedure. Vulva cleaned with Betadine and 3ml of 0.5 percent Xylocaine with epinephrine injected into left vulva and wheal formed. 18 gauge needle then introduced into cyst with scant material returned. Hemostatic at end of procedure. Specimen sent for cytology. How should I report this?

New York Subscriber

Answer: You should consider this to be 10021 (Fine needle aspiration; without imaging guidance). The ob-gyn performed the FNA of a cyst of the vulvar area without image guidance. Image guidance would mean the use of ultrasound while he performed the procedure, not before the procedure as in this case.

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