Ultrasound Extremity non-vascular for lesion in axilla?

[claudiak]

Hello Radiology Coders and Happy Memorial Day Weekend to you!

I hope someone can help me with this. My radiologist dictated a report for a ultrasound extremity non-vascular (cpt 76880) for a nodular area in the axillary region.
Report reads " In the left axilla in region of palpable concern there is a hypoechoic oval, horizontally oriented nodule which appears to be intradermal. There is significant inreased vascularity associated with the periphery of this nodule.

Impression: vascular intradermal nodule in axilla. Clinical followup is recommended. She also stated that 'Ultrasound of the region of interest (axilla) ONLY was performed.

I usually group the axillary area more with the breast than with the extremity category. Do any of you agree? Couldn't she have dictated and coded this a ja 76645 (u/s breast/breasts with a modifier of 52 for reduced service for the exam of ONLY the region of interest? Or am I way off base here? What are your thoughts?

I would appreciate any and all opinions/advice.

Thanks
Claudia K, CPC
Networker

[martha35]

I would stick with the 76880. as it is specific to axilla palpabale abnormality

[joe_physio09]

Hi,

I agree with u that we use to group the axillary region with breast more than with the extremity, but in this case we can code this as 76880.

Please correct me if iam wrong.

Joseph Amalraj Antonisamy CPC-H

[Poodles]

Originally Posted by claudiak

Hello Radiology Coders and Happy Memorial Day Weekend to you!

I hope someone can help me with this. My radiologist dictated a report for a ultrasound extremity non-vascular (cpt 76880) for a nodular area in the axillary region.
Report reads " In the left axilla in region of palpable concern there is a hypoechoic oval, horizontally oriented nodule which appears to be intradermal. There is significant inreased vascularity associated with the periphery of this nodule.

Impression: vascular intradermal nodule in axilla. Clinical followup is recommended. She also stated that 'Ultrasound of the region of interest (axilla) ONLY was performed.

I usually group the axillary area more with the breast than with the extremity category. Do any of you agree? Couldn't she have dictated and coded this a ja 76645 (u/s breast/breasts with a modifier of 52 for reduced service for the exam of ONLY the region of interest? Or am I way off base here? What are your thoughts?

I would appreciate any and all opinions/advice.

Thanks
Claudia K, CPC
Networker

According to the Fall issue of the AMA/ACR Clinical Examples in Radiology, to code for soft tissues are as follows:

axilla- 76880
upper back- 76604-52
lower back- 76705
abdominal wall- 76705
groin- 76880
penis- 76857

there are others, but they (at least to me) seem to make more sense.

Hope that helps,

Patti Downing, RCC