How To Use CPT Code 0354T

CPT 0354T describes the use of optical coherence tomography (OCT) imaging to detect cancer cells in the surgical cavity after breast excision. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0354T?

CPT 0354T can be used to describe the interpretation and reporting of optical coherence tomography (OCT) imaging of the surgical cavity in the breast. This code is used when the provider uses OCT to obtain real-time or referred feedback on the presence or absence of cancer cells in the surgical margins.

2. Official Description

The official description of CPT code 0354T is: ‘Optical coherence tomography of breast, surgical cavity; interpretation and report, real-time or referred.’

3. Procedure

1. The provider applies a probe to the surgical cavity left after breast excision.
2. The probe is connected to a computer that displays microscopic images of the tissue.
3. The provider uses the probe to expose the tissue to light waves and measures the reflection of light from the tissues.
4. The computer displays the images in real-time, allowing the provider to assess whether the surgical margins are clear of cancer cells.
5. After the procedure, the provider or a radiologist interprets the images and reports the findings.

4. Qualifying circumstances

CPT 0354T is used when the provider performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast to detect the presence or absence of cancer cells. This procedure is typically performed after breast excision surgery. The interpretation and reporting of the OCT images can be done by the provider or a radiologist.

5. When to use CPT code 0354T

CPT code 0354T should be used when the provider performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast and provides interpretation and reporting of the images. This code should not be reported when the provider performs optical coherence tomography without interpretation and report (use CPT code 0353T) or when OCT is performed on excised breast or axillary lymph node tissue (use CPT code 0352T).

6. Documentation requirements

To support a claim for CPT code 0354T, the provider must document the following information:

• Indication for the use of optical coherence tomography (OCT) imaging in the surgical cavity
• Date of the procedure
• Start and end time of the procedure
• Interpretation and report of the OCT images
• Findings regarding the presence or absence of cancer cells in the surgical margins
• Signature of the provider or radiologist interpreting the images

7. Billing guidelines

When billing for CPT code 0354T, ensure that the provider performs the interpretation and reporting of the optical coherence tomography (OCT) images of the surgical cavity in the breast. This code should not be reported in conjunction with CPT code 0353T if performed by the same physician. It is important to follow the specific guidelines for reporting OCT codes and to consider any relevant modifiers that may be required for accurate billing.

8. Historical information

CPT code 0354T was added to the Current Procedural Terminology system on January 1, 2015. There have been no updates to the code since its addition.

9. Examples

1. A surgeon performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast during a lumpectomy procedure. The surgeon interprets the images in real-time and reports that the surgical margins are clear of cancer cells.
2. A radiologist performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast after a mastectomy. The radiologist interprets the images and reports the presence of cancer cells in the surgical margins, indicating the need for further excision.
3. A plastic surgeon performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast during breast reconstruction surgery. The surgeon interprets the images and reports that the surgical margins are clear of cancer cells.
4. A breast surgeon performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast during a breast-conserving surgery. The surgeon interprets the images and reports the presence of cancer cells in the surgical margins, leading to additional tissue excision.
5. A surgical oncologist performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast after a lumpectomy. The surgeon interprets the images and reports that the surgical margins are clear of cancer cells.
6. A radiologist performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast during a biopsy procedure. The radiologist interprets the images and reports the presence of cancer cells in the surgical margins, guiding further treatment decisions.
7. A breast surgeon performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast during a breast reduction surgery. The surgeon interprets the images and reports that the surgical margins are clear of cancer cells.
8. A plastic surgeon performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast after a breast implant removal. The surgeon interprets the images and reports the presence of cancer cells in the surgical margins, necessitating additional excision.
9. A surgical oncologist performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast during a mastectomy. The surgeon interprets the images and reports that the surgical margins are clear of cancer cells.
10. A radiologist performs optical coherence tomography (OCT) imaging of the surgical cavity in the breast after a breast biopsy. The radiologist interprets the images and reports the presence of cancer cells in the surgical margins, guiding further treatment decisions.