CPT code 76095 is for a procedure using 3D imaging to guide a needle to a breast lesion for tissue sampling, aiding in accurate diagnosis.
CPT code 76095 is used to describe a stereotactic breast biopsy procedure. This is a minimally invasive procedure where a sample of breast tissue is taken for examination. The process involves using a special mammography machine that helps guide the biopsy needle to the precise location of the abnormality in the breast tissue. This technique is often used when a mammogram shows a suspicious area that cannot be felt during a physical exam. The stereotactic guidance ensures accuracy and helps in diagnosing conditions such as breast cancer.
1. Modifier 26 (Professional Component): This modifier is used when the professional component of the service is being billed separately from the technical component. It is applicable if the healthcare provider is only interpreting the results of the imaging or biopsy and not providing the equipment or facility.
2. Modifier TC (Technical Component): This modifier is used when the technical component of the service is being billed separately. It applies if the provider is only responsible for the equipment, supplies, and technical staff involved in the procedure.
3. Modifier 50 (Bilateral Procedure): This modifier is used if the procedure is performed on both breasts during the same session. It indicates that the service was performed bilaterally.
4. 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 imaging or biopsy is performed in conjunction with other procedures that are not typically reported together.
5. Modifier 76 (Repeat Procedure by Same Physician): This modifier is used if the same procedure is repeated by the same physician on the same day. It indicates that the repeat procedure was necessary.
6. Modifier 77 (Repeat Procedure by Another Physician): This modifier is used if the same procedure is repeated by a different physician on the same day. It indicates that the repeat procedure was necessary and performed by another provider.
7. Modifier 91 (Repeat Clinical Diagnostic Laboratory Test): Although less common for imaging or biopsy, this modifier could be used if the procedure is repeated for clinical reasons, such as confirming results.
These modifiers help ensure accurate billing and reimbursement by providing additional context about the services rendered. It's important for healthcare providers to use the appropriate modifiers to avoid claim denials and ensure compliance with payer requirements.
CPT code 76095 is indeed reimbursed by Medicare, as it is included in the Medicare Physician Fee Schedule (MPFS). The reimbursement for this code, like many others, is subject to the specific guidelines and rates set forth by the MPFS, which outlines the payment amounts for services covered under Medicare Part B.
However, it's important to note that the reimbursement can vary based on geographic location and other factors, as determined by the local Medicare Administrative Contractor (MAC). Each MAC is responsible for processing claims and setting specific payment policies within their jurisdiction, so healthcare providers should verify the reimbursement details with their respective MAC to ensure accurate billing and payment for CPT code 76095.
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