Question: What is the difference between a complete and a limited diagnostic breast US procedure? How do I code a bilateral diagnostic breast US procedure? Is there a code for US exam of the axilla only?
Answer: There are two diagnostic breast US codes; 76641 and 76642.
76641 consists of an US examination of all four breast quadrants, the retroareolar region, and examination of the axilla, if performed. The 2017 non-facility Medicare national average reimbursement = $109.
76642 consists of a focused US examination of the breast limited to the assessment of one or more, but not all of the elements in code 76641 and includes examination of the axilla, if performed. The 2017 non-facility Medicare national average reimbursement = $90.
If a bilateral limited breast US exam is performed, code using bilateral modifier -50 (76642-50) or designate bilaterality and code both 76642-L and 76642-R. Reimbursement is 150% of the unilateral reimbursement value (e.g., $90 + $45 = $135).
If an axillary US only is performed, utilize 76882 (extremity US limited, anatomic specific). The 2017 non-facility Medicare national average reimbursement is $37. An example: Ultrasound of the breast only reveals suspicious lesion,core biopsy reveals IDC. Pt returns for discussion of options and axillary US is performed, code 76882 in addition to the E/M visit.
In all instances, the use of ultrasound, without thorough evaluation of the anatomic region, image documentation, and a final written report, is not separately reportable.