Health Information Management

How to report ultrasound with ultrasound guided biopsy of thyroid

APCs Insider, August 12, 2005

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How to report ultrasound with ultrasound guided biopsy of thyroid

QUESTION: I am looking for clarification on the following scenario: A patient presents with two scripts, one for an ultrasound of the thyroid and one for an ultrasound guided biopsy of the thyroid. Is it appropriate to charge for both the ultrasound (76536) of the thyroid and ultrasound guidance (76942) during the same visit? If yes, should I append a modifier? If the physician takes two biopsies, is it appropriate to charge CPT 76942 (ultrasound guidance) x 2?

ANSWER: Let's start with the two requisitions for the tests, based on the scenario you present. A diagnostic implication (diagnosis) must justify the first requisition for the ultrasound of the thyroid. Use CPT code 76536 (Ultrasound, soft tissues of head and neck [e.g., thyroid, parathyroid, parotid], B-scan and/or real time with image documentation) on the same day as a scheduled ultrasound guided biopsy of the thyroid.

Based on the second requisition--ultrasound guided biopsy of the thyroid--with appropriate medical record documentation, you may report 76942, Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation, as well as 60100, Biopsy thyroid, percutaneous core needle.

Although the physician performed two biopsies, only report one CPT code for the biopsy, regardless of the number of biopsies the physician performs on the same lesion. If the documentation supports separate and distinct lesions biopsied in each lobe of the thyroid, report code 60100 twice.

If a patient has distinct, separate lesions that require the physician to perform separate ultrasound guidance and separate biopsies, and this is clearly documented within the report, report code 76942 for each separately guided biopsy.



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