If a bilateral mammography study is performed, would both sides need to be documented regardless of findings? If one side is negative, should that be included?
When the study performed is a bilateral screening or diagnostic mammogram, both the left and right side should be documented as having been performed or evaluated - either in the technique, findings, or assessment section of the report, regardless of the findings. Note that just providing the procedure performed in the title of the report or in the “procedure requested” does not constitute proper documentation.
The AMA/ACR’s Clinical Examples in Radiology has noted multiple times the need to document the procedures performed within the report. For example, the Spring 2006 Documentation Challenge states:
If the procedure performed is not discussed or mentioned in the radiology report, then coders will not be able to code for that procedure and auditors may not be able to confirm that the procedure was performed.
Clinical Examples in Radiology Volume 2, Issue 2; Spring 2006
Clinical Examples in Radiology Volume 4, Issue 4; Fall 2008
Clinical Examples in Radiology Volume 8, Issue 1; Winter 2012
How should chest tomosynthesis and tomosynthesis of fracture(s) of the upper extremity, lower extremity and spine be reported. Do they have their own CPT code similar to the digital breast tomosynthesis codes 77061-77063?
It is the opinion of the ACR’s Economics Committee on Coding & Nomenclature that chest and musculoskeletal (e.g., upper extremity, lower extremity or spine) tomosynthesis studies be reported with the existing CPT 76100, Radiologic examination, single plane body section (e.g. tomography), other than with urography.
How do you code for a second opinion or reread of a film request?
When a physician’s opinion or advice regarding a specific imaging examination is requested by another physician, and on examination of the imaging examination the consulting physician provides his or her opinion or advice to the requesting physician in a written report, the specific procedure code with a 26 modifier (professional component only) should be reported.
Some Medicare carriers require that a 77 modifier also be used to indicate that a basic procedure or service performed by another physician had to be repeated. Please check with your local Medicare carrier for their guidelines. Other carriers and third-party payers may have different guidelines and may recommend the use of CPT code 76140 (Consultation on X-ray exam made elsewhere, written report).
As noted in the American Medical Association’s Principles of CPT Coding, if a patient comes to an office for a new or established visit and brings the physician his or her medical records, including X-rays, the review or reread of the X-rays would be considered part of the face-to-face evaluation and management (E&M) service provided to the patient and would not be reported separately.
While the second interpretation excerpt from Section 100.1 of the Medicare Claims Processing Manual, Chapter 13, Radiology Services and Other Diagnostic Procedures applies to emergency room patients, the ACR was informed by the CMS National Office (via telephone) that the use of the -77 modifier would apply to other second interpretations as well.
For more information on second opinions, please reference Dr. Richard Duszak’s article Another Unpaid Second Opinion, JACR , Volume 2, Issue 9, Pages 793-794 (September 2005).