I feel it important to correspond to your magazine regarding Dr Linver's article, "Coding and Billing in Breast Imaging [April 2002]." Although the article is of great interest and has many important facts, there are certain statements that should be expanded upon. Coding the diagnosis code is very important as per Dr Linver's article and asking the radiologist to code probably takes time away from the radiologist's productivity, and unless all the radiologists are well trained, coding the ICD/9/CM code probably should not be performed by the radiologist. Coding probably should be left to well-qualified coders.

There are several codes in Dr Linver's Table 3 that are inappropriate for reimbursement. This can lead to fraud and abuse. For the breast biopsy stereotactic code 99241, which is an evaluation and management code, one must be very careful in using this in order to perform the stereotactic core biopsy. It is probably inappropriate for the radiologist who is performing the study to use this code. It may be appropriate for the radiologist to use who initially made the diagnosis if that radiologist spent time with the patient and fulfills the obligation of 99241 to its fullest extent. This obligation includes a history, a mini-physical, and a recommendation. A time allotment is not critical for the radiologist but all of this must be documented. In addition, a unilateral mammogram code 76090 is not accepted by most insurers as a separate billable item for a stereotactic core biopsy. Most insurers consider this as part of the procedure, and I tend to agree with that. The caveat is, if you bill this separately and the insurance company accepts it, so be it, but this is not the usual. In addition, code 99211, as Dr Linver pointed out, does not require the presence of a physician and should not be used as a code for post-stereotactic core biopsy. If the patient comes in a separate day and the radiologist performing the core biopsy actually discusses the result with the patient and goes over the findings and examines the patient to make sure there is no hematoma, then an appropriate consultation code such as 99212 can be used. But, again, the patient must come in separately and all of the criteria again must be fulfilled.

As far as the breast biopsy ultrasound-guided codes are concerned, if the patient already has had an ultrasound and the patient presents to you for an ultrasound core biopsy, code 76645, which is the regular ultrasound code for the breast, is not appropriate since the ultrasound code was already used. The 76942 code is appropriate for ultrasound localization. Again, I am not sure that the codes 99241 and 99211 are appropriate in this setting. As far as the ductography code is concerned, the 76088 is for multiple ducts. The correct code is 76086 for a single duct.

In writing articles of this sort, one must be very careful that the codes used in some respect are insurance-company specific and one certainly should perform an audit as Dr Linver suggested to see if the insurance companies are paying you what the reimbursement is and if, in fact, you have a case for billing a code that you think should be reimbursable.

Dr Linver also failed to mention in his article the importance of second opinion and the appropriate billing for those codes. This really takes almost an article or column in and of itself. Again, I want to emphasize that Dr Linver's article is an excellent starting point and that each practice must look individually at their own operation to see which codes they think are applicable and which codes could create the specter of an outside audit from either Medicare or their insurance companies.

William R. Poller, MD

Pittsburgh

Dr Linver's response:

I very much appreciate Dr Poller's comments. He is indeed correct in pointing out that if radiologists are not familiar enough with coding of breast imaging procedures, they should work with well-qualified individuals who are.

I also agree with him that if one chooses to use the Evaluation and Management codes with invasive breast imaging procedures, one must be very careful to follow all the documentation guidelines, as listed on the CMS web site at www.hcfa.gov/medicare.mcarpti.htm. I do mention this in my article, but the importance of proper documentation cannot be overstated here: improper documentation can certainly be viewed by Medicare as fraud and abuse.

Dr Poller's correction about the 76086 code for a ductogram of a single duct is appreciated. The 76088 code is indeed used only for a ductogram of multiple ducts. His point about many codes being insurance company-specific is also well taken. As I mention in my article, performing an audit of one's own reimbursement for various breast imaging codes from each payor is invaluable in allowing one to continually maximize payments received for services rendered.

Lastly, I agree with Dr Poller that there is a variety of other coding issues that I did not address, including coding and billing for second opinions, primarily because of space constraints.

Michael N. Linver, MD

Albuquerque, NM