Radiology Coding Alert
Know When to Query Provider on Typographical Dictation Errors
Question: On limited breast ultrasound (US), if report states “US images of left breast, enter breast including axilla,” would this be acceptable to mean all four quadrants? Mississippi Subscriber Answer: There are two problems with this report. If the technique of the report reads “enter breast,” you may want to consider the possibility that the provider’s speech recognition software misheard the word “entire” as “enter.” If this is the case, you should send the report back to the provider for an addendum. Clinical Examples in Radiology (Winter 2015) states that, in order to report code 76641 (Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete), the following must be documented: Without documentation of the retroareolar region, you may not consider 76641. Furthermore, in this example, you see that the provider labels the examination as a limited US, 77642 (Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited). Assuming that a limited US was ordered by the referring provider, the interpreting physician does not have the authority to change the exam to a complete US. However, if a complete US was ordered, then you should send the report back to the provider for clarification and an addendum. First, you want to clarify the examination does not include imaging of the retroareolar region. If not, then you may code the exam as a limited US.
Related Articles
Radiology Coding Alert
- 2019 ICD-10:
Dive Into This New Round of 2019 ICD-10-CM Additions and Revisions
Get the hang of all the new ICD-10-CM changes now, just in time for October. [...] - ICD-10-CM Coding:
Wrap Your Head Around This Complex Set of Perinatal Coding Guidelines
Use these examples to gain a clearer picture of a nuanced set of rules and [...] - Consider These Pointers for Aspiration, Arthrocentesis, and Injection Services
Utilize your knowledge of anatomy to make the most calculated coding decisions. There’s a handful [...] - You Be the Coder:
Confirm Number of Views When Reporting Complete Scoliosis Series
Question: If the title of the report states “complete scoliosis series including supine and erect,” [...] - Reader Question:
Clear Up Your Unstageable, Unspecified Pressure Ulcer Coding
Question: What’s the difference between an unstageable pressure ulcer and a pressure ulcer with an [...] - Reader Question:
Know When to Query Provider on Typographical Dictation Errors
Question: On limited breast ultrasound (US), if report states “US images of left breast, enter [...]
