AMA Clinical Examples in Radiology - 2016 Issue 2 (Spring)
Questions and Answers
QUESTIONS AND ANSWERS Question Answer A radiologist is questioning the use of the follow-up obstetric ultrasound examination CPT code 76816 and when to use it. The radiologist feels that if the exam is performed during the first trimester, a complete examination should be coded even if the patient has had an earlier exam. If during the first trimester a complete examination is done as a follow-up to a previous study, is it necessary to bill the follow-up code? As stated in CPT Professional Edition 2016, page 449, "Code 76816 describes an examination designed to reassess fetal size and interval...
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Article Overview
This article collects practical coding questions and responses drawn from radiology scenarios. It focuses on how CPT guidance applies to selected imaging and vascular procedures, with emphasis on choosing among related study types, understanding when follow-up or specialty imaging codes are relevant, and recognizing when modifiers may be involved for separate encounters. It is aimed at radiology coders, billing staff, and clinicians who document or review imaging services.
Why This Topic Matters
Radiology imaging encounters often involve closely related CPT choices, and small differences in indication, modality, or session timing can affect code selection. This Q&A helps readers identify the broad issues that drive proper reporting for common radiology services.
What You Will Learn
- How the article addresses CPT questions in radiology coding
- How imaging indication and exam type affect code selection
- How separate patient encounters are discussed in relation to same-day imaging services
- How the article frames questions involving obstetric, vascular, cardiac, and musculoskeletal imaging
Who Should Read This
- Radiology coders
- Medical billers
- Revenue cycle staff
- Radiologists
- Imaging practice managers
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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