Hello Radiology coders! Happy Memorial Day weekend!
I have a slight dilemma. A referring Dr ordered a us breast for an axillary lump but our radiologist dictated it as US extremity non vascular exam (cpt 76880). She states "In the left axilla in region of palpable concern there is a hypoechoic oval, horizontally oriented nodule wihch appears to be intradermal. There is significant increased vascularity associated with the periphery of this nodule.
Impression: vascular intradermal nodule. Clinical followup is recommended. She also stated that ultrasound of the region of interest ONLY was performed.
I usually group the axillary area more with the breast that with extremity. Do
any of you agree. Couldn't she have coded this a 76645 with a modifer 52 for reduced service for the exam of ONLY the region of interest??? Or am I way off base here? What are your thoughts?\
I would appreciate any and all opinions.
Thanks
Claudia K, CPC, Networker
I have a slight dilemma. A referring Dr ordered a us breast for an axillary lump but our radiologist dictated it as US extremity non vascular exam (cpt 76880). She states "In the left axilla in region of palpable concern there is a hypoechoic oval, horizontally oriented nodule wihch appears to be intradermal. There is significant increased vascularity associated with the periphery of this nodule.
Impression: vascular intradermal nodule. Clinical followup is recommended. She also stated that ultrasound of the region of interest ONLY was performed.
I usually group the axillary area more with the breast that with extremity. Do
any of you agree. Couldn't she have coded this a 76645 with a modifer 52 for reduced service for the exam of ONLY the region of interest??? Or am I way off base here? What are your thoughts?\
I would appreciate any and all opinions.
Thanks
Claudia K, CPC, Networker