Breast Ultrasound Coding Changes for 2015
The CPT® 2015 codebook deleted a familiar breast ultrasound code (76645), while adding two new, more precise codes to describe the same procedure.
- 76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
- 76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited
Code 76641 describes a complete examination of all four quadrants of the breast and the retroareolar region; 76642 describes a limited breast ultrasound (e.g., a focused examination limited to one or more elements of 76641, but not all four). To support the service performed and billed, the provider should document a thorough exam of the anatomic area(s), and provide image documentation and a final, written report of results, impressions, etc.
You may report either 76641 or 76442 once, per breast, per session. Both codes are unilateral: If medical necessity requires bilateral imaging, you may append modifier 50 Bilateral procedure. The 2015 National Physician Fee Schedule Relative Value File (January Release) assigns a “1” bilateral indicator to 76641 and 76442, meaning that Medicare will allow 150 percent of the standard reimbursement for properly billed bilateral procedures.
Both 76641 and 76442 include examination of the axilla, if performed. For ultrasound exam of the axilla, only, see 76882 Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific.