CPT 76098

CPT 76098 – Radiologic examination, surgical specimen

CPT 76098 accurately depicts what a pathologist may do in respect of a breast specimen and its associated mammogram or post-extraction film: the pathologist reviews the x-ray to verify the orientation of the specimen and/or to confirm the precise location of a calcification deposit or lesion so that appropriate sections can be taken for microscopic evaluation.  Even though CPT 76098 in located in the radiology section of the CPT book it can be used by pathologist when review of X-ray is performed and documented within the pathology report. (This isn’t the only time a pathologist might review a surgical specimen x-ray as an integral part of the sample’s workup, but it’s the most frequently encountered use.)

CAP confirms that the cited code may be reported by a pathologist under the described circumstances. It also reminds you that proper documentation of the service is essential to accurate code determination and adequate audit support. {CAP Today, June 2003} The documentation may be included as part of the specimen’s gross description, or it may be set forth in any other logical area of the report. Basically, the added comment has to state (1) that the accompanying x-ray was reviewed by the pathologist, (2) the objective of the review (e.g., confirm lesion’s location), and (3) the action taken (e.g., precise suspect area inked or sampled). Note that the CPT descriptor doesn’t anticipate that a formal “interpretation” will be posted by the pathologist for the x-ray: it’s sufficient that it be reviewed and used in a way that contributes to the diagnosis of the patient. Also, this service must be performed by a physician and not by the pathology assistance during the gross exam without the pathologist personally studying the film too.