Basics of CPT code 76641 & 76641 for Breast Ultrasound

CPT code 76641 for breast ultrasound represents a complete examination of all four quadrants of the breast and the retroareolar region. On the other side, the limited code, 76642, is for a focused exam of the breast that is limited to one or more of the elements included in 76641. You can also learn about ultrasound abdomen complete and limited exam as well, which are quite similar to these codes.

Both the ultrasound procedure CPT code 76641 & 76642 also include an examination of the axilla, if performed. There is a new note in the CPT Manual that directs the assignment of the limited extremity code 76882 if only the axilla is evaluated using ultrasound. These codes can be used for coding ultrasound axillary lymph nodes exam as well.

Description CPT code 76641 & 76642

• 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

Ultrasound, also known as sonography, is an imaging method using sound waves rather than ionizing radiation to a part of the body. For this test, a small, microphone-like instrument called a transducer is placed on the skin (which is often first lubricated with ultrasound gel). It emits sound waves and picks up the echoes as they bounce off body tissues.

The echoes are converted by a computer into a black and white image on a computer screen. Ultrasound is useful for evaluating some breast masses and is the only way to tell if a suspicious area is a cyst (fluid-filled sac) without placing a needle into it to aspirate (draw out) fluid. Cysts cannot accurately be diagnosed by physical exam alone. Breast ultrasound may also be used to help doctors guide a biopsy needle into some breast lesions.

Read also: Coding tips for Diagnostic & Screening mammogram CPT codes

CPT code 93970 & 93971: A Comprehensive Coding Guide

Coding guide for CPT code 76881 & 76882 for Extremity ultrasound

When to use Procedure code 75574, 75580 by Medical coders

For Medicare patients, codes 76641, Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete, and 76642 have a bilateral indicator “1.” As a result, the 150% payment adjustment for bilateral procedures applies. If the procedure code is reported with the bilateral modifier 50 or modifiers RT and LT, payment is based on the actual charge for both sides or 150% of the fee schedule amount for a single code. As stated in the Winter 2015 issue of CER:

Codes 76641 and 76642 are reported once per breast per session; when bilateral procedures are performed, a modifier (eg, RT and LT) should be appended to the CPT code to receive appropriate reimbursement.

It should be noted that the use of modifiers is payer specific. Providers and medical coders should check with their local Medicare Administrative Contractor and third-party payers for guidance on how to report bilateral procedures. Some payers may require the use of modifier 50 when procedures are performed bilaterally. Other payers may require the use of HCPCS Level II code modifiers RT and LT or for the code to be listed on one line with a multiplier.

In Procedure code 76641, a complete unilateral ultrasound examination of the breast is performed. All four quadrants as well as the area directly behind the areola are viewed and evaluated. In code 76642, a focused ultrasound examination is done to assess only a specific area(s) or quadrant(s) of interest in the breast. The physician reviews the ultrasound images of the breast and provides a written interpretation.

The appropriate CPT code to report an ultrasound examination of the breast is 76641, Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete, or 76642, Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited.

If bilateral breast ultrasound study is performed in this setting, the code should be reported once with modifier 50, Bilateral Procedure, or twice – once with an RT modifier and once with an LT modifier to indicate both breasts were imaged.

Per the CPT  codebook, code 76641 represents a complete ultrasound examination of the breast. CPT code 76641 consists of an ultrasound examination of all four quadrants of the breast and the retro-areolar region. It also includes ultrasound examination of the axilla, if performed.

CPT code 76642 consists of a focused ultrasound examination of the breast limited to the assessment of one or more, but not all, of the elements listed in code 76641. It also includes ultrasound examination of the axilla, if performed. If only the axilla is scanned, it should be coded as a limited extremity ultrasound, code 76882.

Complete unilateral Cost (CPT code 76641)

Professional Component (Use of Modifier 26 ) $35.24
Technical Component (use of TC modifier ) $70.15
Global (CPT code without modifier) $105.39

Limited unilateral  Cost (CPT code 76642)

Professional Component $35.04

Technical Component $55.06

Global $90.10

Read also: When to use Breast Biopsy CPT codes in Surgery with imaging guidance

XXX – Global days concept does not apply

Modifiers used with Breast ultrasound CPT code 76641 & 76642

26 – Professional Component A physician who performs the interpretation of an ultrasound exam in the hospital outpatient setting may submit a charge for the professional component of the ultrasound service using a modifier (-26) appended to the ultrasound code.

50 – Bilateral Procedure This modifier would be used to bill bilateral procedures that are performed at the same operative session, unless otherwise identified in the listings. To appropriately adjust payment when bilateral procedures are furnished under the PFS, payments are adjusted to 150 percent of the unilateral payment when a service has a bilateral payment indicator assigned.

TC – Technical Component This modifier would be used to bill for services by the owner of the equipment only to report the technical component of the service. This modifier is most commonly used if the service is performed in an Independent Diagnostic Testing Facility (IDTF).

Regardless of the coding used, full and complete imaging and documentation must be included for each breast separately. When medical necessity determines that a bilateral study is indicated, Medicare will increase reimbursement to 150% of the unilateral rate when a modifier (-50) is added to either code. Other payers (notably Medicaid) do not accept the -50 modifier and will require separate claim lines billed with the LT and RT modifiers to indicate the left and right breast.

CAD (Computer Aided Detection) systems for ultrasound use pattern recognition methods to help radiologists analyze images and automate the reporting process. These systems have been developed to promote standardized breast ultrasound reporting.

In contrast to CAD systems used with mammography, CAD analysis with MRI creates a 2- or 3-dimensional (2-D, 3-D) color-coded image that is overlaid on the MRI image to mark potentially malignant areas of the breast which allows the radiologist to compare the enhanced image to the original MRI.

Documentation Requirements for CPT code 76641 & 76642

Ultrasound performed using either a compact portable ultrasound or a console ultrasound system are reported using the same CPT codes as long as the studies that were performed meet all the following requirements:
• Medical necessity as required by the payer

• Completeness
• Documented in the patient’s medical record A separate written record of the diagnostic ultrasound or ultrasound-guided procedure must be completed and maintained in the patient record. This documentation should mention the structures or organs examined the findings and reason for the ultrasound procedure. Diagnostic ultrasound procedures require the production and retention of image documentation.

It is recommended that ultrasound permanent images, either electronic or hardcopy, from all ultrasound services should be retained in the patient record or other appropriate archive for proper billing.

Note: The description of the new code 76641 states that axilla imaging is not required, but included in the code description if performed. Therefore, if this is part of the examination, it should be documented in the patient files that it was performed.

For Nipple Discharge/Galactorrhea Diagnosis

* Mammogram should be obtained and ultrasound (CPT 76641: unilateral, complete or CPT 76642: unilateral, limited) as initial imaging.
o If mammogram and ultrasound are negative, a ductal excision is indicated. A ductogram may be useful to exclude multiple lesions and to localize lesions before surgery.
o Ductal excision is indicated even if the ductogram is negative.
o An MRI may be considered if a ductogram is technically limited
o For a Birads 4 or 5 based on mammogram and/or ultrasound, biopsy is indicated

Read also:  ICD 10 coding guide for breast mass  in radiology

ICD 10 and PCS codes of breast Ultrasound  CPT code 76641 & 76642 

The most common ICD 10 diagnosis will be breast mass/lump or the presence of breast cyst. You can get all the ICD 10 codes below, but be clever enough to find the accurate ICD 10 codes. Yes, now we have separate codes for each quadrant for breast mass category N63. So coders need to be extra careful while coding N63 category. Same goes for malignant neoplasm of breast condition. Here, also we  have very specifically the correct ICD 10 codes for specific quadrant with the help of O’clock position.

ICD-10-CM (diagnosis) CPT code 76641 & 76642 

R92.0 Mammographic microcalcification found on diagnostic
imaging of breast
R92.1 Mammographic calcification found on diagnostic imaging
of breast
R92.2 Inconclusive mammogram

R92.3 Mammographic density found on imaging of breast
 R92.30 Dense breasts, unspecified
 R92.31 Mammographic fatty tissue density of breast
 R92.311 Mammographic fatty tissue density, right breast
 R92.312 Mammographic fatty tissue density, left breast
 R92.313 Mammographic fatty tissue density, bilateral breasts
 

R92.32 Mammographic fibroglandular density of breast
 R92.321 Mammographic fibroglandular density, right breast
 R92.322 Mammographic fibroglandular density, left breast
 R92.323 Mammographic fibroglandular density, bilateral breasts
 

R92.33 Mammographic heterogeneous density of breast
 R92.331 Mammographic heterogeneous density, right breast
 R92.332 Mammographic heterogeneous density, left breast
 R92.333 Mammographic heterogeneous density, bilateral breasts

 R92.34 Mammographic extreme density of breast
 R92.341 Mammographic extreme density, right breast
 R92.342 Mammographic extreme density, left breast
 R92.343 Mammographic extreme density, bilateral breasts
                                                                                                                                                                                     R92.8 Other abnormal and inconclusive findings on diagnostic imaging of breast

Z12.39 Encounter for other screening for malignant neoplasm
of breast
N60.0 Solitary cyst of breast
N60.01 Solitary cyst of right breast
N60.02 Solitary cyst of left breast
N60.09 Solitary cyst of unspecified breast
N63 Unspecified lump in breast
N63.0 Unspecified lump in unspecified breast
N63.1 Unspecified lump in the right breast
N63.10 Unspecified lump in the right breast, unspecified quadrant
N63.11 Unspecified lump in the right breast, upper outer quadrant
N63.12 Unspecified lump in the right breast, upper inner quadrant
N63.13 Unspecified lump in the right breast, lower outer quadrant
N63.14 Unspecified lump in the right breast, lower inner quadrant
N63.2 Unspecified lump in the left breast
N63.20 Unspecified lump in the left breast, unspecified quadrant
N63.21 Unspecified lump in the left breast, upper outer quadrant
N63.22 Unspecified lump in the left breast, upper inner quadrant
N63.23 Unspecified lump in the left breast, lower outer quadrant
N63.24 Unspecified lump in the left breast, lower inner quadrant
N63.3 Unspecified lump in axillary tail
N6331 Unspecified lump in axillary tail of the right breast
N63.32 Unspecified lump in axillary tail of the left breast
N63.4 Unspecified lump in breast, subareolar
N63.41 Unspecified lump in right breast, subareolar
N63.42 Unspecified lump in left breast, subareolar
ICD-10-PCS
• BH40ZZZ Ultrasonography of Right Breast
• BH41ZZZ Ultrasonography of Left Breast
• BH42ZZZ Ultrasonography of Bilateral Breasts

References:

https://www.cms.gov/medicare/Coding/ICD10/index.html

https://www.oxhp.com/secure/policy/breast_imaging_screen_diagnose_cancer.pdf