The CPT® 2015 Codebook added two new procedure 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 breast ultrasound examination of all four quadrants and the retroareolar region. Code 76642 describes a limited breast ultrasound examination, including one or more elements of 76641, however, not all four. To support the service performed and billed, you should document a thorough exam of the anatomic area(s), and provide image documentation and a final, written report of results and impressions.
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, which means that Medicare will allow 150 percent of the standard reimbursement for properly billed bilateral procedures.
Helpful links for further procedure reimbursement facts: McKesson – Coding for Breast Ultrasound