Breast Biopsy

Message

All Breast tissue must be submitted with a formalin fixation tracking sheet (pink form)

Mammographic directed breast biopsies:
Request on Tissue Examination Request. The X-ray technician assigned will assist with the mammogram procedure brings the tissue to the Pathology Department. This tissue must be submitted fresh (no fixation) to mammography for x-rays. After x-rays are taken, fresh specimen is brought to Histology. Grossing Pathologist is notified.

Needle core/mammotome biopsies:
Submit in an appropriate amount of formalin. For biopsies performed for calcifications, a specimen radiograph should accompany the specimen.

All other breast tissue specimens, (including those requiring radiologic examination, such as wire directed biopsies):
Submit without fixative. Specimens should be delivered to the histology laboratory as quickly as possible in order to be examined by a pathologist and must be transferred into formalin in under 1 hour. This ensures that tissue requiring hormone receptor assays and gene amplification studies is handled in accordance with current formalin fixation guidelines for those studies. If a specimen radiograph is available, the radiograph should accompany the specimen.

Test Code

Breast Biopsy

Instructions

All specimens will be submitted with either a CHCS order entry document or a Tissue Examination Request
[NAVHOSPPTSVA 6510/44 series
It must be completely filled out with:

1. The provider’s full name.
2. The patient’s first and last name.
3. Social security number with FMP.
4. Age.
5. Ward/clinic/MOR.
6. Specimens anatomic site.
7. Two submitting staff initials.
8. Specimen identifier (A, B, C, etc) if more than one container / specimen is to be submitted.
9. Duty station with phone number for active duty personnel.
In addition, pre-operative diagnosis should be included with pertinent clinical data.

Note: All tissue specimens submitted to Histology from internal NMCP sources must have 2 verifying initials on the specimen containers. If they don’t, the specimen will not be accepted. This is command policy. In addition, all patient and specimen source information must be on the specimen container and exactly match the specimen source indicated in the order.

When placing the order in CHCS, the ordering provider must verify that the Patient’s name, FMP, social security number, date of birth and specimen source on the specimen container are correct. Specimens from different body sites must be placed in separate, completely labeled, containers.
Surgical Pathology specimens must be labeled and requisitions prepared in the room where the surgical procedure is performed. The ordering provider must ensure that the specimen container(s) are correctly labeled with complete and correct patient information, including full name, FMP, SSN, and date of birth, and with the correct specimen identifier (A, B, C, etc) and specimen source (body site). The provider should verify that the specimen identifier(s) (A, B, C, etc) and body sites in the orders correspond to the identifier(s) and body sites on the specimen container(s.)

Note:Routine specimens should be submitted in adequate fixative (10% neutral buffered formalin). A volume of fixative 10-20 times the volume of the tissue specimen submitted is required for optimal fixation. In cases where fixative has not been added, the histopathology technician or laboratory technician will add fixative to the container after consulting with a pathologist.

For ships and branch clinics that mail surgical specimens to Naval Medical Center, Portsmouth, a leak proof screw top container that seals tightly must be used in addition to some type of absorbent material in order to avoid fixative leaking during shipment. Fixative leakage results in inadequate tissue preservation, and histological detail is destroyed. Tissue submission request chits should be separate from the tissue container to protect from leakage.

Transport Container

Leakproof specimen container.

Transport Temperature

Room temperature.

Specimen Stability

Specimens should be delivered to the histology laboratory as quickly as possible in order to be examined by a pathologist and must be transferred into formalin in under 1 hour.

Reject Criteria (Eg, hemolysis? Lipemia? Thaw/Other?)

Missing or incomplete patient name on container or lab order form.
Missing or incomplete patient FMP and/or social security number on container or lab order form.
Missing or incomplete anatomic site on container or lab order form.
No double initials on container (two staff members from the submitting clinic must initial the specimen container).
Illegible container label or lab order form.
Patient information on container different from patient information on lab order form.
No lab order form submitted with specimen.
No specimen submitted with lab order form.

Reference Range

Interpretative report.

The CPT Codes provided in this document are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payor being billed. Any Profile/panel component may be ordered separately. Reflex tests are performed at an additional charge.