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Operative Report #1
Preop Diagnosis: Right breast masses on mammography
Postop Diagnosis: Breast masses pending pathology
Procedure Performed: Stereotactic core biopsies

Procedure Description: The procedure and risks were explained to the patient and
consent was obtained. The right breast was positioned and images of the mass in the
upper outer quadrant were obtained posteriorly. The breast was prepped for the
procedure. The area was anesthetized with a local anesthetic, and a small incision was
made in the breast. Using an 8 g Mammotome device, one pass were made through
the area and a specimen was obtained. The specimen was marked as core #1. The
patient’s breast was then repositioned and images of the mass in the central region at
the middle depth were obtained. The area was anesthetized with a local anesthetic,
and a small incision was made in the breast. Using an 8 g Mammotome device a pass
was made and a specimen was obtained from this site as well. The specimen was
marked as core #2. Micromakers were placed at the site of the core biopsies.
There were no complications and the patient was taken to recovery in good condition.

 

What is/are the final ICD-10-PCS code(s) assigned? Two codes are required !

 

 

SCIENCE
HEALTH SCIENCE
NURSING
HIT 240