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Question: A patient presented to a radiology practice with complaints of chronic sinusitis. The patient’s primary care physician referred the patient to the radiology practice after the patient had been suffering from a persistent sinus infection that wasn’t responding to antibiotics. A sinus tract had developed.

The radiologist performed a radiologic examination of the patient’s sinus tract. The provider then evaluated the images to assess the extent of the sinus tract and severity of the infection.

What codes should I use to report this encounter?

Texas Subscriber

Answer: You’ll assign 76080 (Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation) to report the imaging examination performed. The radiologist used the exam to evaluate the patient’s sinus tract and check for the extent of the infection.

During the examination, the radiologist will take initial images of the affected area. Then, they will administer contrast material through a catheter into the sinus tract and capture additional images of the sinus tract.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC