Radiology Coding Alert

Question: The radiologist documents a complete ultrasound (US) of the breast including all four quadrants and the retroareolar region. Should I code a US examination of the axilla separately?

Ohio Subscriber

Answer: There are two sets of guidelines listed in the CPT^® manual that will direct you to the correct answer. First, take a look at the guidelines under the “Chest” subheading in the CPT^® manual:

• “Code 76641 (Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete) represents a complete ultrasound examination of the breast. Code 76641 consists of an ultrasound examination of all four quadrants of the breast and the retroareolar regions. It also includes ultrasound of the examination of the axilla, if performed.”

Additionally, you will see that the parenthetical note listed under 76641 and 76642 (… limited) states that, “for axillary ultrasound only, use 76882 (Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real-time with image documentation).” As the guidelines suggest, you will include imaging of the axilla with a complete US breast, when performed. You will also find guidelines under the “Chest” subsection that instruct you to include imaging of the axilla with any limited ultrasounds of the breast, as well. Only when the axilla is viewed separately from the breast should you consider code 76882.