"Radiological" Examination surgical specimens

May 22, 2017

Question:

Our radiologists are currently performing “ultrasound exam on the surgical specimen” post breast biopsy. As coders, we have been debating on which is the most appropriate code to capture this service. Some coders believe it should be reported with unlisted code 76999, and there are other coders, like myself, who believe it should be reported with code 76098. Rationale for suggesting 76098: Based on CPT description, this code defines “radiological examination, surgical specimen”. While it's customary for this study to be done via x-ray (radiograph), the term “radiological examination” is very broad and does not restrict us to any particular modality as long as a radiological evaluation is done on the specimen(s) obtained.

Question ID: 9404
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