Name of the Procedure:

Documentation of reason(s) for not performing minimally invasive biopsy to diagnose breast cancer preoperatively (HCPCS code G8876)

Summary

This documentation involves recording the specific reasons why a minimally invasive biopsy (such as a needle biopsy) was not performed to diagnose breast cancer before surgery.

Purpose

This documentation is necessary to provide a clear clinical rationale for not performing a minimally invasive biopsy. The goal is to ensure that all patient care decisions are transparent and justified based on individual patient circumstances.

Indications

• The lesion is too close to the skin, an implant, or the chest wall.
• The lesion cannot be adequately visualized for a needle biopsy.
• The patient's medical condition does not permit a minimally invasive procedure.

Preparation

No specific patient preparation is required for this documentation process. However, the patient should have undergone necessary imaging tests, such as mammograms, ultrasound, or MRI, to identify the lesion and the feasibility of a biopsy.

Procedure Description

1. Review the patient's medical record and diagnostic imaging.
2. Assess the feasibility of performing a minimally invasive biopsy.
3. If a biopsy is deemed not feasible, document the specific reason(s) in the patient's medical record, such as:
   • Lesion location too close to skin, implant, or chest wall.
   • Lesion not adequately visualized for needle biopsy.
   • Patient's medical condition precludes the procedure.
4. Ensure the documentation is clear and detailed to support clinical decisions.

Duration

The documentation process typically takes about 15-30 minutes.

Setting

This documentation can be completed in a hospital, outpatient clinic, or surgical center setting.

Personnel

• Physicians (e.g., oncologists, radiologists, surgeons)
• Nurses
• Medical record staff

Risks and Complications

There are no direct risks or complications associated with the documentation process. However, not performing a minimally invasive biopsy could delay diagnosis or alter management plans.

Benefits

• Provides a clear rationale for clinical decision-making.
• Ensures patient safety and appropriate management.
• Aids in maintaining comprehensive medical records.

Recovery

There is no recovery process associated with documentation. However, the patient may need follow-up appointments for further evaluation and management.

Alternatives

• Attempting a minimally invasive biopsy if initial attempts fail.
• Proceeding directly to surgical biopsy if indicated and feasible.
• Using other diagnostic methods like MRI or advanced imaging for lesion characterization.

Patient Experience

Patients may feel anxious or concerned about the inability to perform a minimally invasive biopsy. Healthcare providers should explain the reasons clearly and discuss alternative diagnostic or treatment options. Pain management is not relevant to the documentation process itself but should be considered regarding the overall treatment plan.