AMA CPT® Assistant - 2015 Issue 8 (August)

Modifiers (Q&A) (August 2015)

August 2015 page 8e Modifiers Question: How should a bilateral procedure be reported when the code description only includes the word "unilateral," and there are no bilateral codes? For example, when an ultrasound of both breasts is performed, code 76641, Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete, is reported; however, should the procedure be reported with modifier 50 as single-line item or as separate line items with an anatomic modifier to indicate each side? Answer: If the term "unilateral" is included in the code description and there is no code for "bilateral"...

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CPT® Assistant content is the official source for CPT® coding guidance. It is an instrumental tool when appealing insurance denials and validating coding to auditors. Monthly issues and an extensive archive provide comprehensive guidance on proper CPT® coding for past, present and upcoming code set releases. Archives date back to 1990 for historical use of codes, changes, rationales, coding tips and trends in the industry.

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