Question: What’s the coding for a contrast-only bilateral breast resonance imaging (MRI) scan? Tennessee Subscriber
Answer: According to the CPT® Assistant (August 2019; Volume 29: Issue 8), you will report a unilateral or bilateral MRI of the breast(s) using code 76498 (Unlisted magnetic resonance procedure (eg, diagnostic, interventional)). This claim should be submitted on paper, and you should include proper justification and documentation supporting the use of 76498. Furthermore, you should include the most appropriate comparison code. Since the scan is performed bilaterally, you will report 77049 (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; bilateral). Ensure that that the dictation report includes documentation of CAD.