How To Use CPT Code 76098

CPT code 76098 describes the radiological examination of a surgical specimen using X-ray technology. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 76098?

CPT 76098 can be used to describe the radiological examination of a surgical specimen, such as a breast biopsy, immediately after it is removed from the patient. The purpose of this examination is to confirm that the entire lesion has been excised. The radiologist evaluates the margins of the specimen to ensure they are clear of the lesion and reports the findings to the surgeon before the procedure is completed.

2. Official Description

The official description of CPT code 76098 is: ‘Radiological examination, surgical specimen.’

3. Procedure

1. The surgeon removes a tissue specimen from the patient during a surgical procedure.
2. The radiologist immediately images the specimen using X-ray technology.
3. The radiologist evaluates the margins of the specimen to ensure they are clear of the lesion.
4. The radiologist reports the findings to the surgeon before the procedure is completed.
5. A pathologist may also review the film to determine the best positioning of the specimen for microscopic examination and diagnosis.

4. Qualifying circumstances

CPT 76098 is used when a radiologist examines a surgical specimen using X-ray technology to confirm the excision of the entire lesion. This code should not be reported in conjunction with codes 19081-19086 or 0694T. For 3-dimensional volumetric specimen imaging, use code 0694T.

5. When to use CPT code 76098

CPT code 76098 should be used when a radiologist performs a radiological examination of a surgical specimen immediately after it is removed from the patient. This code is appropriate when the purpose of the examination is to confirm the excision of the entire lesion. It should not be used for other types of radiological examinations or imaging procedures.

6. Documentation requirements

To support a claim for CPT code 76098, the radiologist should document the following information:

• Description of the surgical specimen examined
• Date and time of the examination
• Findings of the examination, including evaluation of the margins
• Report of the findings to the surgeon
• Signature of the radiologist performing the examination

7. Billing guidelines

When billing for CPT code 76098, ensure that the radiologist performs the radiological examination of the surgical specimen using X-ray technology. If only the physician’s interpretation is being reported, append modifier 26 to the radiology code. If only the technical component is being reported, append modifier TC to the radiology code. However, payer policy may exempt hospitals from appending modifier TC. Do not append a professional or technical modifier when reporting a global service in which one provider renders both components.

8. Historical information

CPT code 76098 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A radiologist performs a radiological examination of a breast biopsy specimen immediately after it is removed from the patient to confirm the excision of the entire lesion.
2. A radiologist examines a tissue specimen from a lung surgery using X-ray technology to ensure the margins are clear of the lesion.
3. A radiologist images a surgical specimen from a skin biopsy to confirm the complete removal of the lesion.
4. A radiologist evaluates the margins of a surgical specimen from a gastrointestinal surgery to ensure the absence of the lesion.
5. A radiologist performs a radiological examination of a tissue specimen from a bone biopsy to confirm the excision of the entire lesion.
6. A radiologist examines a surgical specimen from a brain surgery using X-ray technology to ensure the complete removal of the lesion.
7. A radiologist images a tissue specimen from a liver biopsy to confirm the absence of the lesion.
8. A radiologist evaluates the margins of a surgical specimen from a kidney surgery to ensure the excision of the entire lesion.
9. A radiologist performs a radiological examination of a tissue specimen from a prostate biopsy to confirm the absence of the lesion.
10. A radiologist examines a surgical specimen from a thyroid surgery using X-ray technology to ensure the complete removal of the lesion.