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A percutaneous needle core biopsy of the breast is a minimally invasive procedure used to obtain tissue samples from a breast lesion. This procedure is performed without the use of imaging guidance, which means that the physician relies on physical examination and palpation to locate the area of concern. The process begins with the cleansing of the skin over the biopsy site, followed by the administration of a local anesthetic to minimize discomfort for the patient. Once the area is prepared, the physician palpates the lump to accurately identify its location. With one hand stabilizing the lesion, the physician uses the other hand to insert a hollow needle into the lesion. To ensure that a sufficient amount of tissue is collected for diagnostic purposes, multiple core needle insertions—typically between three to six—are performed. After the necessary tissue samples are obtained, they are sent to a laboratory for pathological examination, where they will be analyzed for any abnormalities or signs of disease.
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The percutaneous needle core biopsy of the breast is indicated for the evaluation of various breast abnormalities. These may include:
The procedure for a percutaneous needle core biopsy of the breast involves several key steps to ensure accurate tissue sampling. First, the skin over the biopsy site is thoroughly cleansed to reduce the risk of infection. Following this, a local anesthetic is injected to numb the area, providing comfort to the patient during the procedure. Once the anesthetic has taken effect, the physician palpates the breast to locate the lump or area of concern. This tactile examination is crucial, as it guides the physician in accurately targeting the lesion. With one hand, the physician stabilizes the lesion to prevent movement, while the other hand is used to insert a hollow needle into the lesion. The needle is designed to extract a core of tissue, and to obtain an adequate sample, the physician typically performs between three to six separate insertions. Each insertion is carefully executed to ensure that sufficient tissue is collected for diagnostic analysis. After the tissue samples are obtained, they are placed in appropriate containers and sent to a laboratory for pathological examination, where they will be evaluated for any signs of disease.
After the percutaneous needle core biopsy, patients may experience some discomfort or bruising at the biopsy site, which is generally mild and resolves on its own. It is important for patients to follow any post-procedure care instructions provided by their healthcare provider, which may include keeping the biopsy site clean and dry, avoiding strenuous activities for a short period, and monitoring for any signs of infection, such as increased redness, swelling, or discharge. Patients are typically advised to schedule a follow-up appointment to discuss the results of the pathological examination and any further steps that may be necessary based on those results.
| Short Descr | BX BREAST PERCUT W/O IMAGE | Medium Descr | BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX | Long Descr | Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 4 | CCS Clinical Classification | 165 - Breast biopsy and other diagnostic procedures on breast |
| LT | Left side (used to identify procedures performed on the left side of the body) | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2001-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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