How To Use CPT Code 0638T

CPT 0638T describes the use of computed tomography (CT) to examine both breasts, first without contrast and then with contrast material. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0638T?

CPT 0638T can be used to report a CT examination of both breasts, which includes imaging without contrast and imaging with contrast material. This code may also include 3D rendering, although it is not required.

2. Official Description

The official description of CPT code 0638T is: ‘Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s).’ It is important to note that this code should not be reported in conjunction with certain other codes, such as 76376, 76377, 76380, or 76497.

3. Procedure

1. The patient is positioned on the CT equipment, and multiple cross-sectional images of both breasts are taken.
2. Initially, images are acquired without the use of contrast material.
3. After the non-contrast images are obtained, contrast material is injected into the patient.
4. Additional imaging is performed to capture the contrast-enhanced images.
5. The provider examines the cross-sectional images on a computer monitor and interprets the results.
6. Three-dimensional (3D) rendering of the images may be performed, providing various complex renderings, image recovery, segmentation, and quantitative analysis.

4. Qualifying circumstances

CPT 0638T is used for patients who undergo a CT examination of both breasts, including imaging without contrast followed by imaging with contrast material. This procedure is typically performed to evaluate breast abnormalities or to monitor the effectiveness of treatment. The use of contrast material is important in enhancing the visibility of internal structures or organs of the breasts.

5. When to use CPT code 0638T

CPT code 0638T should be used when a CT examination of both breasts is performed, starting with imaging without contrast and followed by imaging with contrast material. This code is appropriate for bilateral procedures and includes the option for 3D rendering. It is important to review the available options and select the correct code based on the use of contrast and whether the service is unilateral or bilateral.

6. Documentation requirements

To support a claim for CPT code 0638T, the provider must document the following information:

• Indication for the CT examination of both breasts
• Details of the imaging procedure, including the use of contrast material
• Date and time of the procedure
• Results and interpretation of the images
• Documentation of any additional services performed, such as 3D rendering
• Signature of the provider

7. Billing guidelines

When billing for CPT code 0638T, ensure that the procedure meets the criteria described in the code description. It is important to note that this code should not be reported in conjunction with certain other codes, as specified in the notes. Additionally, consider the guidelines for reporting contrast administration and the use of modifiers, if applicable. Review the documentation requirements and ensure that all necessary information is included in the claim.

8. Historical information

CPT code 0638T was added to the Current Procedural Terminology system on January 1, 2021. As of now, there have been no updates or changes to this code.

9. Examples

1. A patient undergoes a CT examination of both breasts, starting with imaging without contrast and followed by imaging with contrast material, to evaluate a suspicious breast mass.
2. A patient with a history of breast cancer undergoes a CT examination of both breasts, including 3D rendering, to monitor the effectiveness of treatment.
3. A patient presents with breast pain, and a CT examination of both breasts is performed to assess for any underlying abnormalities.
4. A patient with a family history of breast cancer undergoes a CT examination of both breasts as a screening tool.
5. A patient with breast implants undergoes a CT examination of both breasts to evaluate the integrity of the implants.
6. A patient with a known breast abnormality undergoes a CT examination of both breasts to determine the extent of the abnormality.
7. A patient with a history of radiation therapy undergoes a CT examination of both breasts to monitor for any radiation-related changes.
8. A patient with a suspected breast infection undergoes a CT examination of both breasts to assess the extent of the infection.
9. A patient with a breast implant rupture undergoes a CT examination of both breasts to confirm the diagnosis.
10. A patient with a history of breast surgery undergoes a CT examination of both breasts to evaluate for any postoperative complications.