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Fine needle aspiration biopsy, including ultrasound guidance; first lesion

CPT4 code

Name of the Procedure:

Fine Needle Aspiration Biopsy, including Ultrasound Guidance; First Lesion
  • Common Names: Fine Needle Aspiration (FNA), FNA Biopsy, Needle Biopsy
  • Technical Term: Fine Needle Aspiration Biopsy with Ultrasound Guidance

Summary

Fine Needle Aspiration Biopsy (FNA) is a minimally invasive procedure used to extract a small sample of tissue or fluid from a suspicious lesion or lump for diagnostic examination. Ultrasound guidance is utilized to accurately locate the first lesion and ensure precise needle placement.

Purpose

Medical Condition:

FNA biopsy primarily addresses the need to diagnose abnormalities such as tumors, cysts, inflammation, or infections that are detectable through imaging or palpation.

Goals:

The primary goal is to determine the nature of a lesion (benign or malignant) to guide subsequent medical treatment or intervention.

Indications

  • Presence of a palpable lump or mass.
  • Abnormal imaging findings (e.g., ultrasound, CT, MRI) that warrant further investigation.
  • Suspicion of cancer based on clinical examination or history.
  • Lymph node evaluation for possible malignancy or infection.

Preparation

  • Patients may be required to fast for 4-6 hours before the procedure.
  • Inform your doctor about any medications you are taking, especially blood thinners.
  • Blood tests may be conducted to check clotting function.
  • An ultrasound or other imaging tests are often performed beforehand to localize the lesion.

Procedure Description

  1. Preparation: The patient is positioned comfortably, and the skin over the biopsy site is cleaned and sterilized.
  2. Anesthesia: A local anesthetic is applied to numb the area.
  3. Ultrasound Guidance: An ultrasound probe is used to locate the lesion and guide the needle.
  4. Aspiration: A fine needle is inserted into the lesion while the ultrasound image is monitored to ensure precise placement. Tissue or fluid is extracted.
  5. Sample Collection: The collected sample is placed in a container for laboratory analysis.
  6. Post-Procedure Care: The site is cleaned, and a small bandage is applied.

Duration

The procedure typically takes about 20-30 minutes.

Setting

Fine Needle Aspiration Biopsy is usually performed in an outpatient clinic, radiology department, or hospital.

Personnel

  • Radiologist or Interventional Radiologist
  • Pathologist (for sample analysis)
  • Ultrasound Technician
  • Nurse or Medical Assistant

Risks and Complications

Common Risks:
  • Mild discomfort or pain at the biopsy site.
  • Minor bleeding or bruising.
Rare Risks:
  • Infection at the biopsy site.
  • Injury to surrounding tissues or structures.
Management:

Complications are generally managed with over-the-counter pain relievers and proper wound care.

Benefits

  • Quick and minimally invasive.
  • Provides valuable diagnostic information.
  • Helps in planning further treatment.

Recovery

  • Post-procedure, patients can usually resume normal activities.
  • Keep the biopsy site clean and dry.
  • Mild soreness can be managed with over-the-counter pain medication.
  • Follow-up appointment may be scheduled to discuss biopsy results.

Alternatives

  • Core Needle Biopsy: Uses a larger needle for more substantial tissue sample; may be preferred for certain lesion types.
  • Surgical Biopsy: Open or excisional biopsy is more invasive but may be necessary if FNA is inconclusive.
  • Watchful Waiting: In some cases, monitoring the lesion over time may be an alternative.

Patient Experience

  • Patients might feel a pinch or slight pressure during needle insertion.
  • Ultrasound guidance is typically painless and helps ensure accuracy.
  • Post-procedure discomfort is usually minor, and pain can be managed with simple analgesics.
  • Most patients can return to their daily routines shortly after the procedure.

Medical Policies and Guidelines for Fine needle aspiration biopsy, including ultrasound guidance; first lesion

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