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Coding for Complete and Limited Ultrasound Breast Imaging

Coding for Complete and Limited Ultrasound Breast Imaging

In 2015, the CPT® codebook deleted breast ultrasound code and replaced it with two, more precise codes:

  • 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.
Report 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 2017 National Physician Fee Schedule Relative Value File 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.

Example 1: Ultrasound exam of four quadrants of left breast and left axilla. Report 76641. Standard reimbursement applies.
Example 2: Complete ultrasound exam of left breast and right breasts (e.g., all four quadrants examined in both breasts): Report 76642-50. Code 76642 is reimbursed at 150 percent of fee schedule value for Medicare payers.
Example 3: Complete ultrasound exam of left breast, with ultrasound exam of two quadrants of the right breast: Report 76642-LT (complete exam of left breast) and 76641-RT (limited exam of right breast). Standard reimbursement applies.

John Verhovshek
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About Has 577 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

5 Responses to “Coding for Complete and Limited Ultrasound Breast Imaging”

  1. Suneethi Venkatesh says:

    Hi John
    In the above article, code 76442 should be changed to 76642.
    Coding example 3 states 76642-LT as complete examination of the breast, but it should be 76641-LT and similarly 76641-RT should actually be 76642-RT

  2. Ms Robinson says:

    I have a claim that denied 76642 RT due to procedure inconsistent with the modifier used How would I distinquish the professional modifier to be used if the exam was only on the right breast

  3. Sasha says:

    Bilateral breast ultrasound payment denied by Medicare stating that medical necessity was not shown. Which code or codes can be successfully used for dense breasts, and cystic breasts.
    Thank you

  4. Darlene Weber says:

    There are multiple typos on this article- expecially the example section. The complete code is 76641, not 76642. Thanks for the article though!

  5. Jojo says:

    Hello I got a denial stating cannot billed cpt 76641-50 and 77066 with dx code N63.0 , do I need to add modifiers or change dx code ?