Search all medical codes

Level V - Surgical pathology, gross and microscopic examination Adrenal, resection Bone - biopsy/curettings Bone fragment(s), pathologic fracture Brain, biopsy Brain/meninges, tumor resection Breast, excision of lesion, requiring microscopic evaluation of

CPT4 code

Name of the Procedure:

Level V - Surgical pathology, gross and microscopic examination

  • Common names: Adrenal resection, Bone biopsy, Bone fragment examination, Brain biopsy, Brain tumor resection, Breast lesion excision

Summary

In this procedure, a tissue sample is taken from the adrenal gland, bone, brain, or breast. The sample is examined both grossly (with the naked eye) and microscopically (under a microscope) to diagnose or rule out diseases such as cancer or other pathological conditions.

Purpose

The procedure is designed to diagnose various conditions involving the adrenal gland, bones, brain, or breast by carefully examining tissue samples. The goal is to detect abnormalities and provide accurate diagnoses to guide effective treatment plans.

Indications

  • Adrenal resection: Indicated for adrenal tumors or hyperplasia.
  • Bone biopsy: Indicated for unexplained bone pain, abnormal imaging results, or persistent bone infections.
  • Bone fragment examination: Necessary for understanding pathologic fractures.
  • Brain biopsy: Used for diagnosing brain lesions, tumors, or infections.
  • Brain tumor resection: Performed to remove brain tumors and evaluate them for malignancy.
  • Breast lesion excision: Indicated for palpable lumps, abnormal imaging findings, or cysts requiring microscopic evaluation.

Preparation

  • Follow fasting instructions if anesthesia is needed.
  • Adjust medications as directed by your doctor.
  • Undergo pre-procedure imaging or blood tests as required.

Procedure Description

  1. Adrenal resection: An incision is made to access and remove the adrenal gland.
  2. Bone biopsy: A needle or small incision is used to collect bone tissue.
  3. Bone fragment examination: Collected fragments from a pathological fracture are submitted.
  4. Brain biopsy: A small piece of brain tissue is removed via a needle or open surgery.
  5. Brain tumor resection: The tumor is surgically removed.
  6. Breast lesion excision: The abnormal tissue is surgically removed for study.
    • Instruments include scalpels, needles, and surgical trays.
    • Local or general anesthesia is utilized as necessary.

Duration

  • Procedure duration varies from 30 minutes to several hours, depending on the complexity.

Setting

  • Typically performed in a hospital, outpatient surgical center, or clinic.

Personnel

  • Surgeons, pathologists, nurses, and anesthesiologists.

Risks and Complications

  • Common: Bleeding, infection, pain at the surgery site.
  • Rare: Anesthesia reactions, accidental damage to nearby tissues or organs.

Benefits

  • Accurate diagnosis of potential malignant or benign conditions.
  • Facilitates targeted treatment planning, potentially improving prognosis.

Recovery

  • Follow specific post-procedure care instructions: wound care, medication.
  • Recovery time varies; minor procedures may allow return to normal activities in a few days, while major surgeries may require several weeks.
  • Attend follow-up appointments for results and further treatment planning.

Alternatives

  • Imaging studies (MRI, CT scans) can suggest but not confirm diagnosis without tissue samples.
  • Less invasive biopsies (e.g., fine-needle aspiration) may be options depending on the situation.

Patient Experience

  • Mild discomfort or pain during and after the procedure, managed with pain relief medications.
  • Post-procedure tiredness or grogginess if anesthesia is used.
  • Close monitoring in a recovery area immediately following the procedure.

Similar Codes