Radiology Coding Alert

The answers might surprise you If you think coding biopsy and rib x-ray reports is a snap, you might be in for a surprise. Our readers submitted the following questions along with their potential coding solutions, and we put our experts to the test.

Take our quiz to determine whether you can determine how to code the following two scenarios: Question 1: An ob-gyn orders a stereotactic breast biopsy for a patient with a left breast mass (ICD-9 611.72 ). The radiologist takes the patient's vital statistics and attempts to localize the abnormality. But he cannot find it, so he cancels the procedure. The practice wants to report 99202 (Office or other outpatient visit for the evaluation and management of a new patient...) but isn't sure whether to report an office visit when  the ordering physician only requested a biopsy. Answer: "The radiologist doesn't need an order from the treating physician to bill an E/M visit," says Jackie Miller, RHIA, CPC, senior consultant at Per-Se Technologies, a medical reimbursement consulting firm in Atlanta. "However, billing for an office visit may not be the best solution in this situation."

Snag: The problem, Miller says, is that the radiologist's documentation must meet the criteria for an E/M service. "For example, in order to bill a 99202, the radiologist would need to document an expanded problem-focused history, expanded problem-focused exam, and straightforward medical decision-making. Depending upon the extent of documentation, it may not be possible to bill an E/M service." No E/M Documentation, No E/M Code Solution: "If the radiologist performed a diagnostic mammogram and canceled the biopsy (before he prepared the surgical field or opened any supplies) because the mammogram showed no abnormality, the practice should report the mammogram only (76090-76091)," Miller says. "If the radiologist performed and documented a history and physical, and the documentation meets criteria for an E/M service, he could bill an office or other outpatient visit."

But if the radiologist started the biopsy procedure (which might include opening surgical supplies or preparing the surgical field) and had to cancel it, you should report the appropriate breast biopsy code (19100-19103) with modifier -53 (Discontinued procedure) appended, Miller says.

Some coders question whether they can report the biopsy that the requesting physician ordered even though they didn't perform it, but you can as long as you append modifier -53, Miller says.

"If the physician starts a surgical or diagnostic procedure but has to discontinue it due to extenuating circumstances, the CPT Codes tells you to report the attempted procedure with modifier -53," Miller says.  "Typically, when the payer receives a claim with this [...]