How To Use CPT Code 77048

CPT 77048 describes the use of magnetic resonance imaging (MRI) to obtain three-dimensional images of one breast, with and without contrast material, including computer-aided detection (CAD) when performed. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 77048?

CPT 77048 can be used to describe the use of MRI to obtain detailed images of one breast, with and without the use of contrast material. This code also includes the use of computer-aided detection (CAD) when performed. It is important to note that this code is specific to imaging of one breast only.

2. Official Description

The official description of CPT code 77048 is: ‘Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral.’

3. Procedure

1. The provider uses an MRI scanner with a strong magnetic field to obtain three-dimensional images of the breast.
2. Radiofrequency waves are applied to the breast, causing the hydrogen atoms in the body to release radio signals.
3. A computer receives these signals and converts them into detailed images of the breast.
4. If necessary, a contrast material may be injected intravenously to enhance the visibility of internal structures or organs of the breast.
5. After the diagnostic contrast-enhanced MRI scans are taken, a CAD software program may be used to analyze the images and produce colorized images reflecting areas of abnormal perfusion.
6. The provider evaluates the images and data before finalizing their findings and dictating a report.

4. Qualifying circumstances

CPT 77048 is used for imaging of one breast only. It is typically performed when there is a need to investigate the anatomy of the breast using MRI. The use of contrast material and CAD may be included in the procedure, depending on the specific circumstances and the provider’s judgment.

5. When to use CPT code 77048

CPT code 77048 should be used when a provider performs an MRI of one breast, with and without contrast material, and includes the use of CAD when necessary. It is important to ensure that the procedure is performed on one breast only and not both. If imaging of both breasts is required, a different code should be used.

6. Documentation requirements

To support a claim for CPT 77048, the provider must document the following information:

• Indication for the MRI of the breast
• Whether contrast material was used and the specific contrast agent
• Details of the CAD analysis, if performed
• Date and time of the procedure
• Any additional findings or observations
• Signature of the provider

7. Billing guidelines

When billing for CPT 77048, ensure that the procedure involves imaging of one breast only. If imaging of both breasts is required, a different code should be used. It is also important to document the use of contrast material and CAD, if applicable. Providers should follow payer guidelines for reporting contrast separately, if necessary. Modifier 26 should be appended to the radiology code if reporting only the physician’s interpretation, and modifier TC should be appended if reporting only the technical component. However, payer policies may vary, so it is important to check individual guidelines.

8. Historical information

CPT 77048 was added to the Current Procedural Terminology system on January 1, 2019. There have been no updates to the code since its addition.

9. Examples

1. A provider performs an MRI of one breast, with and without contrast material, and uses CAD to analyze the images for a patient with a suspected breast abnormality.
2. During an MRI of one breast, a provider identifies a suspicious lesion and uses CAD to further characterize the abnormality.
3. A patient with a history of breast cancer undergoes an MRI of one breast, with and without contrast material, to monitor for any recurrence or new abnormalities.
4. A provider performs an MRI of one breast, with and without contrast material, for a patient with a family history of breast cancer and a genetic mutation associated with increased risk.
5. During an MRI of one breast, a provider uses CAD to assist in the detection and characterization of a known breast abnormality.
6. A patient with breast implants undergoes an MRI of one breast, with and without contrast material, to evaluate the integrity of the implant and assess for any associated abnormalities.
7. A provider performs an MRI of one breast, with and without contrast material, to evaluate a patient with persistent breast pain and no previous imaging abnormalities.
8. During an MRI of one breast, a provider uses CAD to aid in the detection and analysis of a suspected breast abnormality.
9. A patient with a recent breast biopsy undergoes an MRI of one breast, with and without contrast material, to assess for any residual abnormalities or complications.
10. A provider performs an MRI of one breast, with and without contrast material, for a patient with a newly diagnosed breast abnormality identified on mammography.