Radiology Coding Alert

Question: Our physician did a thyroid sonogram to evaluate a thyroid mass. How can we report this procedure?

Massachusetts Subscriber

Answer: The appropriate code is 76536 (Ultrasound, soft tissues of head and neck [e.g., thyroid, parathyroid, parotid], real time with image documentation) for thyroid ultrasound examination.

Bonus tip: Remember to append modifier 26 (Professional component) if you’re coding only the professional service. This rule holds true even if the radiologist performs the ultrasound herself, in addition to providing the interpretation and report. CPT^® Assistant (May 2009) explains that for services performed in a facility setting, “even if the professional acts as the sonographer, use of the code without a modifier is not appropriate as the facility has provided the room and most likely the equipment.”