Breast Ultrasound Coding Changes for 2015
- By John Verhovshek
- In Coding
- January 27, 2015
- 8 Comments
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.
John Verhovshek
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Medicare has been denying 76641 with a 50 modifier!
We use modifiers RT and LT, instead of 50
As a patient this coding change has affected me greatly. Last year I had a bilateral ultrasound (76645) the allowable amount w/ BCBSGA was $136. I had the exact procedure Jan 2015 billed with the new code (76642 times 2) $254.10 allowable amount each, for a grand total of $508. Using Rt & Lt modifiers. At least with a 50 modifier it should be paid at 150%. Why is there not a universal standard for coding a bilateral US with the new code? Many women will be having second thoughts before having this potentially life saving procedure now due to the extreme cost hike.
when a 50 mod is used for the bilateral breast u/s; do we use qty 1 or qty 2?
BcBs denied cpt code 76641 (noncovered) billed along with cpt codes G0202 and 77052 no modifiers attached (2 codes paid) , should I add modifier 50 or rt/lt modifier to the cpt code 76641
Thank you for your comment. You’ll find a lot of suggestions and better answers to your question in the Member Forums.
I am also a patient and the change in coding has become a hardship for me. I need to have a bi-lateral ultrasound each year and now with the new coding (76641) I am being charge twice and now owe $741.42. When the code (76645) was used it would be one charge and all I owed was $368.40. I have had problems in the past and that is why I need the ultrasound but going forward I am reconsider having the ultrasound as for the higher amount I will owe.
Charging per breast is just insane!