Radiology Coding Alert

Question: A patient presented for a screening breast magnetic resonance imaging (MRI) examination. The referring physician documented the reason for the exam as “dense breast tissue.” The radiologist’s findings were unremarkable.

Should I use a screening or dense breasts code as the principal diagnosis code?

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Answer: You should use a screening code, such as Z12.39 (Encounter for other screening for malignant neoplasm of breast), to report this encounter. While the referring provider indicated the patient’s dense breast tissue was the reason for the screening MRI, the radiologist still performed a screening exam.

According to CPT^® Assistant, Volume 29, Issue 12, you’ll assign one of the following breast MRI codes “for abbreviated breast MRI (AB-MRI) for cancer screening for women with dense breast tissue:”

• 77048 (Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral)
• 77049 (… bilateral)

Of course, you can always contact the individual payer to confirm how they prefer you to report this unique situation.