CPT code 76090 is for a mammogram of one breast, used by healthcare providers to document and categorize this specific diagnostic procedure.
CPT code 76090 is used to describe a mammogram procedure that involves imaging of one breast. This code is typically used when a healthcare provider needs to examine only one breast for diagnostic purposes, such as investigating a lump or other abnormality. The mammogram is an X-ray technique that helps in the early detection and diagnosis of breast diseases, primarily breast cancer. By focusing on a single breast, this procedure allows for a more targeted approach to identifying potential issues.
When considering whether CPT codes 76088 and 76090 require any modifiers, it's important to understand the context in which these procedures are performed. Modifiers are used to provide additional information about the performed procedure, such as changes in service, bilateral procedures, or unusual circumstances. Below is a list of potential modifiers that could be applicable:
1. Modifier 26 (Professional Component): This modifier is used when only the professional component of the service is provided. For example, if a radiologist interprets the X-ray or mammogram but does not own the equipment, this modifier would be applicable.
2. Modifier TC (Technical Component): This is used when only the technical component of the service is provided. It applies when the facility provides the equipment and technical support but not the interpretation.
3. Modifier 50 (Bilateral Procedure): If the procedure is performed on both breasts, this modifier would be applicable to indicate that the service was bilateral.
4. Modifier 52 (Reduced Services): This modifier is used when a service or procedure is partially reduced or eliminated at the physician's discretion. It might apply if, for some reason, the full mammogram or X-ray procedure was not completed.
5. Modifier 59 (Distinct Procedural Service): This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. It may be necessary if the X-ray or mammogram is performed in conjunction with other procedures.
6. Modifier 76 (Repeat Procedure by Same Physician): If the procedure needs to be repeated on the same day by the same physician, this modifier would be applicable.
7. Modifier 77 (Repeat Procedure by Another Physician): This is used when a procedure is repeated on the same day by a different physician.
8. Modifier 91 (Repeat Clinical Diagnostic Laboratory Test): While typically used for laboratory tests, if the procedure is repeated for clinical reasons, this modifier might be considered, though it is less common for imaging services.
Each modifier should be applied based on the specific circumstances of the procedure and payer requirements. It is crucial to verify with the specific payer guidelines to ensure proper usage and reimbursement.
CPT code 76090 is subject to reimbursement considerations under Medicare, but whether it is reimbursed can depend on several factors, including the specific circumstances of the service provided and the policies of the Medicare Administrative Contractor (MAC) in your region.
The Medicare Physician Fee Schedule (MPFS) outlines the payment rates for services covered by Medicare, including those related to CPT code 76090. However, it is essential to verify with the local MAC, as they have the authority to make determinations on coverage and reimbursement specifics.
Additionally, coverage may vary based on whether the service is deemed medically necessary according to Medicare guidelines. Therefore, healthcare providers should consult the MPFS and their regional MAC for the most accurate and up-to-date information regarding reimbursement for CPT code 76090.
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