Radiology Coding Alert
Post-Mastectomy Ultrasound
Oregon Subscriber
Answer: Coding experts disagree about correct coding in this instance. Many recommend that the code for a breast ultrasound (76645, echography, breast[s] [unilateral or bilateral], B-scan and/or real time with image documentation) be reported. They point out that the clinical reason for the ultrasound may be scarring from the breast surgery, or recurrent or residual breast cancer in the chest wall. Therefore, the exam is indeed an ultrasound study of breast tissue (albeit cancerous and abnormal tissue).
Others recommend that the chest ultrasound code (76604, echography, chest, B-scan [includes mediastinum] and/or real time with image documentation) be reported since the chest wall is the structure being studied.
Coders should contact the payer in question and request written direction about which service to report.
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