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Cytopathology
Superpage

Revised: 20 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.


Ultrasound-Guided Fine-Needle Aspiration (USFNA)
General

Authors: Joe D. Jakowski M.D., Susan Meanor R.D.M.S., R.T. (see Reviewers page)
Revised: 23 March 2013, last major update March 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

General
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Why pathologists should perform Ultrasound-guided fine-needle aspiration (USFNA)
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Additional references
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Ultrasound-Guided Fine-Needle Aspiration (USFNA)
Similarities and Differences between USFNA and Traditional Palpation-Guided Fine Needle Aspiration (PGFNA)

Authors: Joe D. Jakowski M.D., Susan Meanor R.D.M.S., R.T. (see Reviewers page)
Revised: 23 March 2013, last major update March 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

General
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The performance of USFNA additionally requires
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Ultrasound-Guided Fine-Needle Aspiration (USFNA)
Certification and Certificates in USFNA

Authors: Joe D. Jakowski M.D., Susan Meanor R.D.M.S., R.T. (see Reviewers page)
Revised: 6 June 2013, last major update March 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

General
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CAP (USFNA AP3)
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ACE (ECNU)
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Ultrasound-Guided Fine-Needle Aspiration (USFNA)
Credentialing, Credentialed, Privileged, and Accreditation in US and USFNA

Authors: Joe D. Jakowski M.D., Susan Meanor R.D.M.S., R.T. (see Reviewers page)
Revised: 23 March 2013, last major update March 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

Credentialing
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Credentialed
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Privileged
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Accreditation
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Ultrasound-Guided Fine-Needle Aspiration (USFNA)
Documentation and Billing / CPT Coding in USFNA

Authors: Joe D. Jakowski M.D., Susan Meanor R.D.M.S., R.T. (see Reviewers page)
Revised: 23 March 2013, last major update March 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

See subtopics below: documentation and billing, CPT coding, E/M codes

Documentation and billing in USFNA
General
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CPT coding in USFNA and US medicine (partial list)
Current procedural technology (CPT)™
Procedure codes
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10022
Fine needle aspiration; with imaging guidance

76942
Ultrasound-guidance of needle placement (e.g., biopsy, aspiration, imaging supervision and interpretation)

Pathology professional and technical codes
=========================================================================

88172
Cytopathology, evaluation of fine needle aspirate; immediate evaluation for adequacy of specimen(s)

88173
Cytopathology, evaluation of fine needle aspirate; Final interpretation and report

88305
CELL BLOCK: Level IV - Surgical pathology, gross and microscopic examination

88104
Cytopathology, fluids; smears with interpretation

Limited ultrasound examination CPT codes
=========================================================================
76857
Ultrasound, BUTTOCK and PERINEUM, real time with image documentation

76705
Ultrasound, ABDOMINAL WALL and LOWER BACK, real-time with image documentation

76536
Ultrasound, HEAD and NECK (e.g., thyroid, parathyroid, parotid), real time with image documentation

76604
Ultrasound, CHEST WALL and UPPER BACK, real time with image documentation

76645
Ultrasound, BREAST(s) (unilateral or bilateral), real time with image documentation

76882
Ultrasound, AXILLA, GROIN, UPPER and LOWER EXTREMITY, nonvascular, real time with image documentation


CPT coding in USFNA and US medicine (partial list)
Evaluation and management (E/M) codes (i.e. office visit codes)
General
=========================================================================
NEW patient E/M codes
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99201
Office or other outpatient visit (10 min) for the evaluation and management of a new patient which have these components or criteria for documentation and billing purposes
  1. Requires 3 key components:
    1. Focused history
    2. Focused exam
    3. Straightforward medical decision
  2. Patient has a self limited or minor problem:
    1. Minimal number of diagnoses or management options
    2. Minimal or no data to be reviewed
    3. Minimal risk of complications, morbidity, mortality
  3. Physician time: 10 minutes
99202
Office or other outpatient visit (20 min) for the evaluation and management of a new patient which have these components or criteria for documentation and billing purposes
  1. Requires 3 key components:
    1. Expanded problem focused history
    2. Expanded problem focused exam
    3. Straightforward medical decision
  2. Patient has a low severity or moderate severity problem:
    1. Limited number of diagnoses or management options
    2. Limited amount or complexity of data to be reviewed
    3. Low risk of complications, morbidity, mortality
  3. Physician time: 20 minutes
Established patient E/M codes
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Ultrasound-Guided Fine-Needle Aspiration (USFNA)
Pathologist Education and Training in US medicine and USFNA

Authors: Joe D. Jakowski M.D., Susan Meanor R.D.M.S., R.T. (see Reviewers page)
Revised: 5 June 2013, last major update March 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

General
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How to obtain education and hands-on training in US medicine and USFNA
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Clinical images
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Turkey phantom



Ultrasound-Guided Fine-Needle Aspiration (USFNA)
Equipment

Authors: Joe D. Jakowski M.D., Susan Meanor R.D.M.S., R.T. (see Reviewers page)
Revised: 23 March 2013, last major update March 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

Desirable equipment and supplies for USFNA of superficial sites
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Supplies for FNA smear making, rapid interpretation, and triage of FNA sample
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Clinical images
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Basic supplies
Ultrasound supplies
Post-aspiration
Rapid interpretation
Triaging



Ultrasound-Guided Fine-Needle Aspiration (USFNA)
Technique of Ultrasound-Guided Needle Placement

Authors: Joe D. Jakowski M.D., Susan Meanor R.D.M.S., R.T. (see Reviewers page)
Revised: 23 March 2013, last major update March 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

General
=========================================================================
Key steps to performing an USFNA
=========================================================================
  1. Obtain proper patient and US machine positioning, adequate room lighting, and all necessary equipment
  2. "Find" and confirm target of interest for FNA using the US transducer (can use a surgical ink pen to make marks on skin if needed)
  3. Plan the best needle approach to the target using information from the US images (e.g. depth and relation to surroundings structures such as bones or large vessels)
  4. Cleanse the skin with antiseptic (70% isopropyl alcohol wipes, providone iodine, chlorhexidine) at site of needle entry
  5. Recheck for proper orientation of US transducer with respect to US display screen and patient
  6. Place needle under ultrasound guidance using one of two approaches defined by orientation of needle with respect to transducer US beam: parallel technique or perpendicular technique
Parallel technique
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Perpendicular technique
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Clinical images
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Perpendicular technique
Parallel technique



Ultrasound-Guided Fine-Needle Aspiration (USFNA)
Procedure Assistance in Pathologist Directed USFNA

Authors: Joe D. Jakowski M.D., Susan Meanor R.D.M.S., R.T. (see Reviewers page)
Revised: 22 March 2013, last major update March 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

General
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Ultrasonographer
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Cytotechnologist, nurse, pathology residents and fellows
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Ultrasound-Guided Fine-Needle Aspiration (USFNA)
Technique of Ultrasound Scanning

Authors: Joe D. Jakowski M.D., Susan Meanor R.D.M.S., R.T. (see Reviewers page)
Revised: 23 March 2013, last major update March 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

General
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Clinical images
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Holding transducer



Ultrasound-Guided Fine-Needle Aspiration (USFNA)
Ultrasound Terminology

Authors: Joe D. Jakowski M.D., Susan Meanor R.D.M.S., R.T. (see Reviewers page)
Revised: 23 March 2013, last major update March 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

General imaging terminology
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Basic ultrasound machine function terminology
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Key ultrasound terms used to describe the sonographic image and US wave interactions with tissues
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Palpation Guided Fine Needle Aspiration
General

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 19 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.
PubMed Search: PGFNA

Fine Needle Aspiration Definitions
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History of Fine Needle Aspiration
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c. 1000 1833 1844 1846 1853 1912 1921 1925 1927 1930 1931 1933 1934 1936 1940 1950's 1951 1954 1957 1958 1961 1966 1970 1974 1979 1983 1985 1986 1987 1989 1990 1993 1995 1996 1997 2003 2007

Additional references
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Palpation Guided Fine Needle Aspiration
General Step by Step FNA Procedure

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 19 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.

General
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Background of FNA procedure
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Pre FNA Procedure Events
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Performing the FNA Procedure
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Palpation Guided Fine Needle Aspiration
Analysis of FNA Procedure and Diagnosis

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 18 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.

General
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Error Rates
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Statistical analysis of FNA diagnoses
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FNA Site Sensitivity Specificity Accuracy PPV NPV FP FN
Salivary Gland 76-83% 93-98% 89-96% 87-90% 94% 0.5-6% 0-16%
Thyroid 65-98% 72-100% 75-90% 94-99% 66-97% 0-8% 1-12%
Breast 73-97% 78-100% 91-93% 92-99% 86-92% 0.5-2% 3-5%
Lymph Node (including benign/reactive vs. all types of lymphoma* vs. metastasis) 30-97% 67-100% 72-97% 82-99% 81-93% 0.9-4% 3-27%
Bone and Soft Tissue Tumors 79-96% 72-98% 73-95% 67-99% 82-92% 1-5% 2-15%

Additional references
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Palpation Guided Fine Needle Aspiration
CTP™ and E/M codes

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 18 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.

Current Procedural Technology (CPT)™ Coding (Partial List)

Procedure codes
=========================================================================

10021
Fine needle aspiration; without imaging guidance

Pathology professional and technical codes
=========================================================================

88172
Cytopathology, evaluation of fine needle aspirate; immediate evaluation for adequacy of specimen(s)

88173
Cytopathology, evaluation of fine needle aspirate; final interpretation and report

88305
CELL BLOCK: Level IV - Surgical pathology, gross and microscopic examination

88104
Cytopathology, fluids; smears with interpretation


Evaluation and management (E/M) codes (i.e. office visit codes)

General
=========================================================================

NEW patient E/M codes
=========================================================================

99201
Office or other outpatient visit (10 min) for the evaluation and management of a new patient which have these components or criteria for documentation and billing purposes
  1. Requires 3 key components:
    1. Focused history
    2. Focused exam
    3. Straightforward medical decision
  2. Patient has a self limited or minor problem:
    1. Minimal number of diagnoses or management options
    2. Minimal or no data to be reviewed
    3. Minimal risk of complications, morbidity, mortality
  3. Physician time: 10 minutes
99202
Office or other outpatient visit (20 min) for the evaluation and management of a new patient which have these components or criteria for documentation and billing purposes
  1. Requires 3 key components:
    1. Expanded problem focused history
    2. Expanded problem focused exam
    3. Straightforward medical decision
  2. Patient has a low severity or moderate severity problem:
    1. Limited number of diagnoses or management options
    2. Limited amount or complexity of data to be reviewed
    3. Low risk of complications, morbidity, mortality
  3. Physician time: 20 minutes

Established patient E/M codes
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Palpation Guided Fine Needle Aspiration
Superficial FNA Procedure: Contraindications and Complications

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 18 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.

General
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Contraindications
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Complications
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Complications following thyroid FNA
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Additional rare FNA complications to consider
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Pneumothorax: Post FNA infarction of the target and additional biopsy tissue alterations: Needle track seeding by tumor: Fatalities:

Other Considerations
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Palpation-Guided Fine-Needle Aspiration
Documentation and Billing in FNA

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 18 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.

General
=========================================================================




Palpation Guided Fine Needle Aspiration
Equipment and supplies for FNA

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 18 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.

General
=========================================================================

Specifications of needles (approximate) (Sigma-Aldrich):
Needle Gauge Outer Diameter (mm) Inner Diameter (mm)
22 0.72 0.41
23 0.64 0.34
25 0.51 0.26
27 0.41 0.21

Anatomy of an Aspiration Needle and Syringe
=========================================================================

Hollow Bore Needle Parts: Syringe Parts:

Supplies for FNA smear making, rapid interpretation, and triage of FNA sample
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Palpation Guided Fine Needle Aspiration
Patient History and Exam

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 19 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.

Focused Patient History and Physical Exam for the FNA Patient
=========================================================================

Evaluating the Patient History of Symptoms: Physical Examination of the Patient’s Lump:

Physical Exam Signs and Findings to Assess the Differential Diagnoses of in the FNA Patient
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General: Common Painful Skin Tumors: Can be remembered by using the pneumonic "LEND AN EGG": (J Am Acad Dermatol 1993;28:298) Sister Mary Joseph sign or node: palpable nodule of the umbilicus as a result of metastasis of a pelvic or abdominal cancer (most commonly gastric, colonic or pancreatic cancer or gynecologic tract cancer in women)

Virchow's node: lymph node in the left supraclavicular fossa that is enlarged, firm, and strongly indicative of metastatic cancer from the abdomen (especially gastric cancer); differential also includes lymphoma, other intra abdominal malignancies, breast cancer, and infection (e.g. of the left arm)

Dimple sign or Fitzpatrick's sign: dimpling of the skin with lateral compression, considered by many to be pathognomonic for dermatofibroma

Transillumination test: Positive Tinel's sign: paresthesias / pain / tingling elicited by mechanical stimulation over the distribution of the nerve suggest peripheral nerve tumors (schwannona, neurofibroma)




Palpation Guided Fine Needle Aspiration
Smear Making and Special Techniques for Recovering and Dividing Aspirate Material

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 19 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.

Overview
=========================================================================

Type of FNA material obtained for smear making
=========================================================================

Solids: IMPORTANT: This firm solid material may be best triaged by picking it off the slide and submitting it for cell block or perhaps performing a touch preparation or a squash preparation instead of attempting to make a smear

Semisolid and special types of semisolids: Fluid:

Transferring FNA material from needle onto glass slide
=========================================================================

General: IMPORTANT: No smearing technique can correct clotting artifact

Techniques to ensure best results in transferring FNA material from needle to glass slide include:

Types of smear making methods
=========================================================================

General:

One step Smear Method
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General: Technique: Smear problems:

Two step Pull Method
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General: Technique: Smear problems:

Pop off Method
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General: Technique:

Simple Wick Concentration Method
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General: Technique:

Simple Incline Concentration Method
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General: Technique:

Two step Method for Concentration
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General: Technique:

Modified Two step Method for Concentration
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General: Technique:

Method(s) for dividing a single smear into several smears
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General: Technique #1: Technique #2:

Additional Special Techniques for Recovering Aspirate Material
=========================================================================

Needle Snap Technique: to recover material trapped in the hub of the needle Syringe Pop Technique: to recover material trapped in the tip or barrel of the syringe by rapidly and forcefully blowing it onto the surface of the glass slide


Palpation Guided Fine Needle Aspiration
Fine Needle Biopsy Technique

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 19 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.
PubMed Search: Fine-Needle Biopsy Technique

General
=========================================================================

Fine Needle Biopsy Techniques
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  1. Fine Needle Aspiration Biopsy (also known as traditional FNA, suction or aspiration biopsy):
  2. Capillary action Needle Biopsy (also known as the French, Zajdela, needle only or non aspiration technique):

Comparison of the Capillary (non aspiration technique) to traditional (suction) FNA
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Amount of specimen collected from an FNA
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Palpation Guided Fine Needle Aspiration
Training in Superficial FNA Procedure

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 19 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.

General
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Important Factors
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Achieving Proficiency
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Overall Strategies and Goals
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Additional Components
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Additional references
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End of Cytopathology > Superpage


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