Pathologist US Guided FNA & Core Bx FNA BIOPSY CONSULTATION JOHN S. ABELE, MD OUTPATIENT PATHOLOGY ASSOCIATES 3301 C Street; Suite 103C Sacramento, CA 95816 916-444-0889 voice 916-444-6016 fax abele@outpatientpathology.com Moira Kelly, Service Representative ** US = 3D Palpation = GPS for FNA ** Illustrative Cases Equipment Basic Technique Billing & Reimbursement Learning Models & References 1096, 1% 2980, 3% 4255, 4% 22952, 22% FNA SAMPLES 1984 2005* (N = 102,053) 30162, 30% 40608, 40% BREAST THYROID LN/SOFT TISSUE SALIVARY GLAND PROSTATE MISC FINE NEEDLE ASPIRATION CASES SITE 2005 % 1984-2005* % BREAST 725 14 30162 30 THYROID 3272 63 40608 40 SOFT/LN 901 17 22952 22 SALIVARY 141 3 4255 4 PROSTATE 0 0 2980 3 MISC 130 3 1096 1 5,169 102,053 Outpatient Pathology Associates Sacramento, CA 95816 Outpatient Pathology Associates Sacramento, CA 95816 U/S = Palpation in 3 rd Dimension Pathologist US Guided Benefits Deep Palpation & Bx Posterior Thyroid Edges Carotid / Trachea False Physical Image Patient Communication Better Sample Than Radiologist Market Forces - TTHALTS John S. Abele,MD Page 1 of 13
Case 1 59 y/o 3CM Thigh Mass 59 y/o male 4 x 2 cm distal thigh mass Hard, enlarging Benign Freatures: Wider than Tall Smooth, Pushing Borders 59 y/o 3CM Thigh Mass Case 2 81 y/o female L Br 2:30, 31 x 26mm Targeting US = WNL Just lateral -> 9mm shadow Breast Nodule: FNA & Core Breast Nodule: FNA & Core John S. Abele,MD Page 2 of 13
Breast Nodule: FNA & Core Thyroid Anatomy Grant s Atlas of Anatomy 1962 Left Thyroid Anatomy Left Thyroid Anatomy Surgically Absent Thyroid Case 3 59 y/o female 20 yr hx thyroid nodules 39 x 31mm dom nodule US = Large Rt cyst, vascular solid component on the wall -Image Orientation -Landmarks John S. Abele,MD Page 3 of 13
Cyst Drainage Tension Cyst Cyst Aspiration Baxter I.V. Extension 34 Male Luer 4cc Catalogue 2C6227 Adapted from Boccato P. FNA biopsyof small targets. Acta Cytol.1987 Mar-Apr;31(2):200-1. Cyst Drainage Cyst Drainage Cyst Aspiration Cyst Drainage John S. Abele,MD Page 4 of 13
Cyst Drainage Sonosite Corp 21919 30th Drive SE Bothell, WA 98021-3904 (888) 482-9449 www.sonosite.com Sonosite: Accessory Monitor Proper Neck Postion before U/S Find Nodule Center Bx Site with Pen Shadow John S. Abele,MD Page 5 of 13
Cutaneous Mark Pen Shadow to Center Nodule Anesthesia: 30 Gauge CUTANEOUS ANESTHESIA http://www.pattersondental.com 800-873-7683 Needles Plastic Hub 30 GA #100 $9 #085-5569 Lidocaine Cart 2% Epi l:100,000 #50 $19 #085-3978 Carbocaine Cart 3% #50 $21 #085-4075 Aspirating Cartridge Syringe Holder $45 #222-4228 CUTANEOUS ANESTHESIA AREOLAR ANESTHESIA X X X X John S. Abele,MD Page 6 of 13
Dry Skin, Needle in, Probe on, Biopsy 3 2 US Gel Obscuration - Heavy 1 U/S Phantom U/S Side: Centered Dry skin, Needle in, Probe on, Biopsy http://www.pharminnovations.com http://www.bluephantom.com Instrument View * Monitor View ** U/S End Bx Needle Image High... Hub Higher *Parallel U/S Plane **Perpendicular U/S Plane w/ Patient s Left = Monitor Left John S. Abele,MD Page 7 of 13
U/S End: Top U/S End: Top End Side End Side End / Side = 3 / 1 Side: + Faster, Less Tissue Traversed - Not Continuous; Tissue Distortion End: + See Continuously, No Distortion - Slower, Alignment Much Trickier U/S: Markings U/S End: Bore Site U/S Side: Markings U/S End: Markings U/S End : Poor Sighting How Core Benefits Br FNA Prove Invasion Material for Special Studies Mobile / Soft Target FAD / Low Tension Cyst FAD vs. Circumscribed CA Colloid / Medullary / Met CA Backup to FNA John S. Abele,MD Page 8 of 13
FNA Push, Not Bx FNA Push, Not Bx Breast Mass Breast Mass 11mm Throw Core Biopsy Materials Monopty Instrument, 11 or 22 mm Outer Cannula 7 mm Core Cavity Jennifer M. Smith Product Manager Bard Biopsy Systems 1415 West 3rd Street Tempe, AZ 85281 480-303-2781 Phone 480-449-2570 Fax Inner Stylette 11 Throw www.bardbiopsy.com John S. Abele,MD Page 9 of 13
Outer Cannula Inner Stylette Cocked (Yellow) - Ready Fired - 11mm Throw... 11mm Throw Fired - Core Cut Remove Instrument Open 1 Click Extract Core 20g Breast Core Biopsy Close w/2ed Click - Ready John S. Abele,MD Page 10 of 13
Core Bx: Relative Sizes 20g Core www.bardbiopsy.com No 20g Core Situations Excluding Ca Calcifications Vague Asymmetry 19100 Breast Core w/o Guidance 19102 Breast Core with Guidance 76xxx Diagnostic Ultrasound -Permanently recorded images -Written report for patient s record CPT 2006 AMAPage 303 DIAGNOSIS diaginosko (dee-ag-in-o'-sko) dia = by means of ginosko (ghin-oce'-ko) = to know DIAGNOSIS = to know by means of to know thoroughly U/S Image Documentation for 76942 U/S Image Documentation for 76942 http://www.cortexmed.com 2107 Elliott Avenue, Suite 201 Seattle, WA 98121 Judith Krebs jkrebs@cortexmed.com 206-826-5032 or 800.278.4645 John S. Abele,MD Page 11 of 13
Billing/Paid Jan-June 2006 Billing/Paid Jan-June 2006 Item CPT # Billed Paid Range FNA Bx US FNA Bx US Img\Rpt FNA DX Rapid Head/Neck Breast Extremity 10021 10022 76942* 88173 88172 76536* 76645* 76880* 434 278 327 1988 29 123 29 * Requires Permanent Image & Written Report 151.00 175.00 150.00 169.00 175.00 150.00 150.00 108.69 121.99 116.74 118.33 53.72 95.99 72.27 144-63 160-57 150-72 155-56 56-45 135-70 86-49 15 150.00 110.76 125-89 Item CPT # Billed Paid Range Core Core\US US Img\Rpt Section Office 30** No FNA Office 15* 19100 19102 76942 88305 99242 99242 99241 ** 2 sites, complex, translator * 1 site 1 9 327 5567 336 336 420 200.00 275.00 150.00 188.00 94.00 94.00 64.00 136.00 241.19 116.74 132.26 80.00 80.00 51.78 150-72 94-75 94-75 64-41 Radiology 2005; 237:794-800 Brant WE. The core curriculum: Ultrasound. 2001 Thy = 10 of 509. Radiology 2005; 237:794-800 Radiology 2005; 237:794-800 Academy of Clinical Thyroidologist (www.thyroidologists.com) John S. Abele,MD Page 12 of 13
Madjar: Practice of Breast Ultrasound Lanfranch Breast Ultrasound John S. Abele,MD Page 13 of 13