All exams must be ordered except screening mammogram. In a hospital situation, the radiologist may order the breast ultrasound if it is medically necessary. In an office or IDTF you would have to get an order from the patient's treating physician.
You can bill both 76645 and 76942 if a diagnostic ultrasound is done and then based on the findings an ultrasound guided procedure such as biopsy is done, or if 76942 is done for something unrelated to the breast ultrasound. What you cannot do is code 76645 for localizing a known lesion prior to biopsy or other procedure.
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