Radiology Coding Alert

Reader Questions:

Familiarize Yourself With Breast Ultrasound Documentation Guidelines

Published on Tue Mar 26, 2024

Question: I have a radiology report stating the provider captured “ultrasound images of the patient’s right breast, entire breast, including axilla.” The documentation doesn’t indicate whether the exam was limited or complete, and it contains no information about the retroareolar region.

How much information do I need to report the procedure?

Alabama Subscriber

Answer: You will need the radiologist to confirm more information before you can assign a code for the encounter. According to the CPT^® guidelines, “Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final written report, is not separately reportable.”

The CPT^® code set includes guidelines on what information the provider needs to document for 76641 (Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete) and 76642 (… limited).

To report 76641, the documentation must show the provider performed an examination of the following:

All four breast quadrants
Retroareolar region
Axilla, if performed

To report 76642, the documentation must show the provider performed a focused examination of one or more elements listed in 76641, but not all the elements. This code also includes axilla examination if the provider performs the service.

Reach out and query the provider to clarify if the imaging included the retroareolar region. If they tell you they performed a limited ultrasound on the patient’s right breast, then you should send the report back to them for clarification and an addendum.