AMA Clinical Examples in Radiology - 2020 Issue 1 (Winter)
Radiology Test Case Answer
RADIOLOGY TEST CASE ANSWER Bilateral Breast MRI With and Without Contrast with CAD HOW TO CODE 77049 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; bilateral Z85.3 Personal history of malignant neoplasm of breast DISCUSSION This report describes bilateral breast MRI without and with contrast, including CAD for a post-mastectomy patient. Therefore, it is appropriate to report the study with CPT code 77049, Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when...
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Article Overview
This article explains a radiology test case involving breast MRI coding and related diagnosis coding, with emphasis on CPT breast MRI categories, a historical code update, and ICD-10-CM diagnosis support. It is aimed at coders, radiology billing staff, and clinical documentation teams who need to understand how the topic is framed in a coding education context and what general guidance sources are referenced.
Why This Topic Matters
Breast MRI studies are commonly coded in radiology workflows, and this article helps readers understand the coding topic, the related diagnosis framework, and the fact that the discussion includes both current and retired code references. It is useful for teams reviewing documentation, coverage, and coding education materials.
Article Sections
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How to Code
Introduces the coding-focused portion of the article and frames the radiology service being discussed. It identifies the broad coding areas addressed in the test case answer.
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Discussion
Provides the explanatory discussion around breast MRI reporting, related diagnosis coding, post-mastectomy context, and historical code updates. It also references broader imaging and coverage context from radiology and Medicare sources.
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Sources
Lists the published references and educational materials used to support the article. The section identifies the organizations and reference types consulted.
What You Will Learn
- How the article frames a breast MRI coding scenario
- Which coding systems are referenced in the discussion
- What general documentation and coverage topics are connected to the case
- Which sources are cited for the educational answer
- How the article situates current and deleted breast MRI-related coding references
Who Should Read This
- Radiology coders
- Medical billing staff
- Coding educators
- Clinical documentation specialists
- Revenue cycle teams
Codes Discussed
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