Several passes into one target

Referral and examination

Synthetic record, September 9, 2026. An adult has an enlarging 1.1 cm palpable subcutaneous nodule on the left forearm. The clinician documents one target for diagnostic fine-needle aspiration. No second lesion is identified for sampling.

Signed procedure note

The clinician performs fine-needle aspiration biopsy of that nodule without imaging guidance. Four needle passes sample the same target to obtain adequate material. No core-needle biopsy, excision or second-target aspiration is performed. The puncture site is dressed without complication.

Specimen record

Material from the four passes is placed on separately labeled slides and submitted under the same left-forearm target. The cytology result is pending. Multiple slides and collection passes are documented, but all come from the same lesion.

Coding worksheet

A proposed FNA procedure charge uses four units, one for each pass. Review only the FNA procedure units under Medicare NCCI. The worksheet does not ask for pathology-service units or infer a final diagnosis from the pending cytology.

Your coding worksheet

1. Count separately identifiable lesions sampled.
2. Distinguish passes from service units.
3. Explain why slide count does not settle procedural units.
4. Correct the proposed unit reasoning under the cited rule.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.