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Answer: CPT Code 76098 (radiological exami-nation, surgical specimen) is used when the radiologist exams a tissue specimen removed during surgery from any part of the body. The most common use of this code occurs when a surgeon removes tissue (the specimen) from the breast after the lesion has been localized with a wire by a radiologist. The radiologist uses x-ray to examine the specimen, looking for evidence that the wire is in the removed specimen. The radiologist can then confirm that the appropriate area was biopsied. And the radiologist may direct the pathologist to an area or areas within the specimen for identification. In other instances, a radiologist may perform a biopsy using a rotating needle, vacuum-assisted device (e.g., ABBI, Mammotome) and then x-rays the specimen to make certain that the questionable tissue is contained in the sample.
Rarely would x-rays of the breast be taken after a lesion has been removed, as suggested in the question. If this were to occur, it may be reported as a unilateral mammogram (76090). Most payers consider such mammographic images to be bundled into other services performed the same day, such as 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 services include the procedure and physician interpretation of the results, including any number of films to ensure that the procedure has been completed.
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