Outpatient Facility Coding Alert

Question: Should I report 76536 for ultrasound (US) guidance during a total thyroidectomy? Is the ultrasound separately billable? The physician documents that the US is for incision site planning and to further evaluate the extension of the tumor.

Wyoming Subscriber

Answer: You should not report 76536 (Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation) for any US that the physician performs intraoperatively. If the physician opts to perform a US prior to surgery for evaluation and planning purposes, 76536 would be appropriate.

For an intraoperative US, you should report 76998 (Ultrasonic guidance, intraoperative). A National Correct Coding Initiative (NCCI, or CCI) check will reveal that no edit exists between 60220 (Total thyroid lobectomy, unilateral; with or without isthmusectomy) and 76998. However, you should be prepared to appeal a denial with the appropriate documentation to support 76998.

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