Ask a Rev Cycle Expert: MRI Breast Imaging Reporting?
When magnetic resonance imaging (MRI) is performed on patients with a mastectomy, we perform the MRI on the remaining breast. For the breast that had the mastectomy, we image the chest wall and axillary area, and provide an interpretation. Should a bilateral or unilateral be reported?
For your scenario, consider reporting the service as a bilateral procedure. Although the mastectomy has been performed, there may be residual breast tissue left behind. The tissues examined can include the axilla, skin, pectoral muscles and chest wall, etc.
Disclaimer: This information was current at the time of its publishing and is designed to provide accurate information in regard to the subject matter covered. Vitalware does not accept any responsibility or liability with regard to any errors, omissions, misuses, or misinterpretation by the reader. It is not intended to take the place of either the written policies or regulations. We encourage you to review the specific regulations and other interpretive materials as necessary. All CPT® codes are trademarked by the American Medical Association (AMA) and all revenue codes are copyrighted by the American Hospital Association (AHA).