CPT® codes

Location: Outpatient Hospital

PREOPERATIVE DIAGNOSIS: Minimal change disease

POSTOPERATIVE DIAGNOSIS: Same

PROCEDURE PERFORMED: Native kidney biopsy

PROCEDURE: After obtaining consent, the patient was taken to ultrasound room. She was put in the prone position. Both kidneys were difficult to visualize. The right kidney was chosen. Skin was prepped in the usual fashion. Lidocaine was used for local anesthesia.

Using real-time ultrasound guidance, the right kidney was accessed multiple times. At least six core biopsies were obtained and were sent for light and electromicroscopy in addition to immune fluorescence. Post biopsy ultrasound showed no evidence of hematoma.

The patient tolerated the procedure well without immediate complication. She was sent back to the procedure area.

what is the CPT® code for this scenario

re: CPT® codes

I used to code interventional radiology I loved it! It has been a couple years but I will toss you the codes I would select.

First identify the guidance-ultrasound for biopsy-76942-26 ( if you are billing for the provider only and not the facility use -26) I never coded a second ultrasound for a post biopsy.
I am going to say this is a needle biopsy because there is no documentation of an incision and the report says "core biopsies" 50200.

Are you also wanting to code for the pathology reports?