Radiology Coding Alert

Question: I have an op note that states the radiologist captured “US (ultrasound) images of left breast, entire breast, including axilla.” There isn’t any indication in the documentation of the retroareolar region or whether they performed a limited or complete exam.

Do I need more information to code the procedure?

Florida Subscriber

Answer: Yes, you do need more information to code the US procedure. The best place to start is by querying the provider to clarify if the imaging included the retroareolar region.

According to the instructions listed prior to 76604-76642 (Ultrasound, …) in the CPT^® code set, code 76641 (…, breast, unilateral, real time with image documentation, including axilla when performed; complete) requires you to document the following:

• All four breast quadrants
• Retroareolar region

If the provider indicates they did examine all four breast quadrants and the retroareolar region, you’ll assign 76641.

However, if the provider tells you they performed a limited US of the patient’s breast, then you should send the report back to them for clarification and an addendum. For you to use code 76642 (…; limited), the report needs to include documentation of “one or more, but not all of the elements listed in code 76641,” according to CPT^® instructions.