Radiology Coding Alert

Question: When should I report CPT 76098 ? Should it be used when x-rays are taken of the breast after a lesion has been removed?

Maine Subscriber

Answer: You should report 76098 (Radiological examination, surgical specimen) when the radiologist examines a tissue specimen removed during surgery regardless of the specimen's body part of origin.
 
Coders commonly report 76098 when a surgeon removes tissue (the specimen) from the breast after the radiologist localizes the lesion with a wire. The radiologist uses x-ray technology to examine the specimen, looking for evidence that the physician removed the complete area of interest for pathologic examination. The radiologist can then confirm that the physician biopsied the appropriate area.
 
For example, a radiologist may perform a biopsy using a rotating needle, vacuum-assisted device (for example, ABBI or Mammotome) and then x-ray the specimen to ensure that the sample contains the questionable tissue.
 
Radiologists rarely order additional breast x-rays after removing a lesion, but if this does occur, you should report it as a unilateral mammogram (76090, Mammography; unilateral) and document the medical necessity for postbiopsy films. Most payers bundle these mammographic images into other services performed the same day, such as those described by 76095 (Stereotactic localization guidance for breast biopsy or needle placement, each lesion, radiological supervision and interpretation) and 76096 (Mammographic guidance for needle placement, breast, each lesion, radiological supervision and interpretation).
 
Both of these codes include the procedure and physician interpretation of the results, including any number of films, to ensure that the procedure has been completed.