Radiology Coding Alert
Familiarize Yourself With Breast Ultrasound Documentation Guidelines
Question: I have a radiology report stating the provider captured “ultrasound images of the patient’s right breast, entire breast, including axilla.” The documentation doesn’t indicate whether the exam was limited or complete, and it contains no information about the retroareolar region. How much information do I need to report the procedure? Alabama Subscriber Answer: You will need the radiologist to confirm more information before you can assign a code for the encounter. According to the CPT® guidelines, “Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final written report, is not separately reportable.” The CPT® code set includes guidelines on what information the provider needs to document for 76641 (Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete) and 76642 (… limited). To report 76641, the documentation must show the provider performed an examination of the following: To report 76642, the documentation must show the provider performed a focused examination of one or more elements listed in 76641, but not all the elements. This code also includes axilla examination if the provider performs the service. Reach out and query the provider to clarify if the imaging included the retroareolar region. If they tell you they performed a limited ultrasound on the patient’s right breast, then you should send the report back to them for clarification and an addendum.
Radiology Coding Alert
- CPT® 101:
Stretch Your Spinal X-ray Coding Knowledge
Plus, improve your view type understanding. As a radiology coder, you’re sure to see a [...] - ICD-10-CM:
Identify Which Image Tests are Needed for Urinary Stone Dx
Remember to use one code for abdominal and pelvic CT scans. Regardless of whether your [...] - Cybersecurity:
Protect Patient Privacy While Deploying New Tech
Add HC3 to your list of helpful healthcare acronyms. As new technologies are deployed to [...] - You Be the Coder:
Nail Down the Correct Nephrostogram Code
Question: We received a claim denial for a nephrostogram procedure. We billed for the physician and [...] - Reader Questions:
Code Fluoroscopy Procedures Longer Than 60 Minutes Correctly
Question: I have a radiology report in my workflow that states the provider performed 90 minutes [...] - Reader Questions:
Choose Between Screening and Dense Breast Codes for AB-MRI Exams
Question: A patient presented for a screening breast magnetic resonance imaging (MRI) examination. The referring physician [...] - Reader Questions:
Familiarize Yourself With Breast Ultrasound Documentation Guidelines
Question: I have a radiology report stating the provider captured “ultrasound images of the patient’s right [...]
