10006 Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (List separately in addition to code for primary procedure)

Name of the Procedure:

Fine Needle Aspiration Biopsy, including ultrasound guidance; each additional lesion

Summary

A Fine Needle Aspiration Biopsy (FNAB) using ultrasound guidance is a minimally invasive procedure that uses a thin needle to extract tissue or fluid from a mass or lesion for diagnostic purposes. Ultrasound imaging is used to accurately guide the needle to the target area. This description applies to the biopsy of each additional lesion, separate from the primary procedure.

Purpose

The medical condition or problem it addresses:

This procedure is used to diagnose or evaluate abnormalities such as lumps (masses), cysts, or other lesions in various body parts. It is often used in the diagnosis of cancer, infections, or inflammatory conditions.

The goals or expected outcomes of the procedure:

The primary goal is to obtain a tissue or fluid sample for analysis to determine the nature of the lesion, whether benign or malignant, and to provide guidance for further treatment.

Indications

Specific symptoms or conditions that warrant the procedure:

• Abnormal lumps or masses
• Suspicious lesions detected on imaging studies
• Swollen lymph nodes
• Unexplained fluid-filled cysts

Patient criteria or factors that make the procedure appropriate:

Indicated for patients with lesions that are inaccessible or difficult to diagnose through less invasive methods, and where accurate diagnosis is critical for planning treatment.

Preparation

Pre-procedure instructions for the patient:

• Fasting is generally not required unless specified by a doctor.
• Inform the healthcare provider about any medications, allergies, or underlying health conditions.
• Blood tests may be required to check blood clotting parameters.

Any diagnostic tests or assessments required beforehand:

• Ultrasound, CT scan, or MRI may be performed to locate the lesion(s) accurately.
• Blood tests to ensure a safe procedure.

Procedure Description

Detailed step-by-step explanation:

1. The patient is positioned comfortably, and the skin over the target area is cleaned and sterilized.
2. Ultrasound imaging is used to locate the lesion precisely.
3. Local anesthesia may be administered to numb the area.
4. A thin needle is inserted through the skin into the lesion under continuous ultrasound guidance.
5. A sample of tissue or fluid is aspirated (suctioned) into the needle.
6. The needle is withdrawn, and the sample is sent to a laboratory for analysis.

Tools, equipment, or technology used:

• Ultrasound machine
• Thin, hollow needle
• Syringe for aspiration
• Sterile drapes and antiseptic solutions

Anesthesia or sedation details, if applicable:

Typically, local anesthesia is used to minimize discomfort. General anesthesia or sedation is rarely needed.

Duration

The procedure usually takes about 15 to 30 minutes, depending on the number and complexity of lesions.

Setting

The procedure is typically performed in an outpatient clinic, radiology department, or sometimes in a hospital setting.

Personnel

Healthcare professionals involved:

• Radiologist or surgeon (performs the procedure)
• Ultrasound technician (operates the ultrasound equipment)
• Nurse or medical assistant (provides support)

Risks and Complications

Common and rare risks associated with the procedure:

• Bleeding or bruising at the puncture site
• Infection
• Pain or discomfort
• Very rarely, injury to adjacent structures

Possible complications and their management:

• Hematoma or infection may require additional medical intervention.
• Pain management with over-the-counter pain relievers or prescribed medication.

Benefits

Expected benefits and how soon they might be realized:

• Minimally invasive with quick recovery
• Provides accurate diagnosis, aiding in effective treatment planning
• Results are typically available within a few days to a week

Recovery

Post-procedure care and instructions:

• Apply an ice pack to the puncture site to reduce swelling.
• Keep the area clean and dry.
• Avoid strenuous activities for 24 hours.

Expected recovery time and any restrictions or follow-up appointments:

• Recovery is usually immediate, with patients resuming normal activities within a day.
• Follow-up appointments may be scheduled to discuss biopsy results and further treatment.

Alternatives

Other treatment options available:

• Core needle biopsy
• Surgical biopsy
• Imaging studies without biopsy (if applicable)

Pros and cons of alternatives compared to the described procedure:

• Core needle biopsy provides a larger sample but is more invasive.
• Surgical biopsy is the most definitive but involves more risk and longer recovery.
• Imaging studies alone may not provide a definitive diagnosis.

Patient Experience

What the patient might feel or experience during and after the procedure:

• Mild discomfort or pressure during needle insertion.
• Slight soreness or bruising after the procedure.

Pain management and comfort measures:

• Local anesthesia helps minimize pain during the procedure.
• Over-the-counter pain relievers can manage post-procedure discomfort.
• Ice packs to reduce swelling and pain.