Part B Insider (Multispecialty) Coding Alert

Question: Our physician performed a breast biopsy and placed a metallic localization clip using radiologic guidance. He then confirmed the clip placement on a mammogram. How can we report this? Can we report the mammogram separately?

Answer: Depending upon the type of radiological guidance used, you may report code 77021 (Magnetic resonance guidance for needle placement [e.g., for biopsy, needle aspiration, injection, or placement of localization device] radiological supervision and interpretation), 77012 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation), 77031 (Stereotactic localization guidance for breast biopsy or needle placement [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation), or 77032 (Mammographic guidance for needle placement, breast [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation). These radiologic guidance codes are inclusive of all imaging needed to complete the procedure. You do not separately report the mammogram in this case.

Therefore, you will not additionally report any mammography codes like +77051 (Computer-aided detection [computer algorithm analysis of digital image data for lesion detection] with further review for interpretation, with or without digitization of film radiographic images; diagnostic mammography [List separately in addition to code for primary procedure]), +77052 (Computer-aided detection [computer algorithm analysis of digital image data for lesion detection] with further review for interpretation, with or without digitization of film radiographic images; screening mammography [List separately in addition to code for primary procedure]), 77055 (Mammography; unilateral), 77056 (Mammography; bilateral), or 77057 (Screening mammography, bilateral [2-view film study of each breast]).