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Cytopathology
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
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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
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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
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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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End of Cytopathology > Ultrasound-Guided Fine-Needle Aspiration (USFNA) > Documentation and Billing / CPT Coding in USFNA


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