Radiology Coding Alert

Question: Does CPT^® code 77048 need a modifier indicating laterality?

Oklahoma Subscriber

Answer: As you see in the code description, 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) is an inherently unilateral procedure. That means that it’s got a bilateral surgery indicator of “0,” stating that in no instances should you bill 77048 bilaterally.

In theory, the use of modifiers RT (Right Side) or LT (Left Side) should be allowed to indicate to the payer which side the physician performed the procedure, but often payers prefer that you leave off any laterality modifiers for procedures that are inherently unilateral. If you receive an incorrect modifier denial, then you should document the payer and make a note to submit without modifiers RT or LT in the future. Additionally, a simpler approach is to incorporate a universal practice guideline for coders to submit unilateral breast magnetic resonance imaging (MRI) scans without appending modifiers RT or LT.