Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgica
CPT4 code
Name of the Procedure:
Level IV - Surgical pathology, gross and microscopic examination
Summary
This involves the examination of tissue samples taken during various medical conditions, such as spontaneous or missed abortions, artery biopsies, bone marrow biopsies, bone exostosis, brain or meninges without tumor resection, and breast biopsies. The analysis helps to diagnose diseases or evaluate the effectiveness of treatment.
Purpose
The procedure aims to diagnose or monitor diseases by examining tissue samples. It helps in detecting abnormalities at the cellular level, understanding the cause of medical conditions, and guiding treatment decisions.
Indications
- Unexplained miscarriages or missed abortions
- Suspected arterial diseases
- Blood disorders or cancers requiring bone marrow analysis
- Abnormal bone growths (exostosis)
- Neurological symptoms without evident tumors
- Breast abnormalities requiring biopsy without the need for surgical margin analysis
Preparation
- Fasting may be required for several hours before the biopsy.
- Patients might need to adjust or stop certain medications (e.g., blood thinners).
- Pre-procedure imaging studies or blood tests may be necessary.
Procedure Description
- Sample Collection: Tissue samples are obtained through various biopsy techniques depending on the condition (e.g., needle biopsy, surgical extraction).
- Fixation: Samples are preserved in a fixative solution to prevent degradation.
- Gross Examination: A pathologist visually examines the tissue for any obvious abnormalities.
- Microscopic Examination: The tissue is sliced into thin sections, stained, and inspected under a microscope.
- Diagnosis: Findings are documented and reported to the treating physician.
- Tools: Scalpels, biopsy needles, fixative solutions, microscopes.
- Anesthesia: Local or general anesthesia may be used, depending on the biopsy type.
Duration
The procedure itself typically takes around 30 minutes to an hour. The examination process may take a few days to complete.
Setting
The biopsy is usually performed in a hospital, outpatient clinic, or surgical center. The pathological examination is conducted in a laboratory.
Personnel
- Surgeons or interventional radiologists (for biopsy procedures)
- Pathologists
- Nurses
- Anesthesiologists (if sedation is required)
Risks and Complications
- Bleeding
- Infection
- Pain or discomfort at the biopsy site
- Rare complications specific to the biopsy site (e.g., nerve damage)
Benefits
- Accurate diagnosis of diseases
- Timely treatment initiation
- Better understanding of medical conditions
- Improved prognosis and management
Recovery
- Patients can often go home the same day.
- Care instructions include keeping the biopsy site clean and protected.
- Pain management with over-the-counter or prescribed medications.
- Follow-up appointments for results and further treatment.
Alternatives
- Imaging studies (e.g., MRI, CT scans) can identify abnormalities but may not provide a definitive diagnosis.
- Blood tests for indirect assessments of conditions.
- Non-invasive monitoring and active surveillance.
Pros: Less invasive alternatives may pose fewer risks and require no recovery time.
Cons: May not provide as accurate or definitive a diagnosis as a pathological examination.
Patient Experience
- Patients may feel anxiety or mild discomfort during the procedure.
- Pain is usually minimal and managed with medication.
- Most patients recover quickly and can resume normal activities within a day or two.