What is the cpt code for bilateral breast ultrasound

As noted in the October 2015 Quarterly Update in the Medicare Physician Fee Schedule Database, bilateral surgery indicators for CPT® codes 76641(Ultrasound Breast Complete) and 76642 (Ultrasound Breast Limited) have been changed from “1” to”3.”

A bilateral surgery indicator of “1” subjects a procedure to a 150 percent payment adjustment, while indicator “3” states that the usual payment modification for bilateral procedures does not apply, i.e., no bilateral adjustment will be made.

Retroactive to January 1, 2015, Medicare will base the payment on the lower of the actual charge for each side or 100 percent of the fee schedule amount for each side for bilateral breast ultrasound procedures reported with modifier -50 or RT and LT. Bilateral surgery is defined as those procedures performed on both sides of the body in a single session or during the course of a single day.

Note that retroactive adjustments will not be made unless brought to the attention of the Medicare Administrative Contractor. Be sure to contact your MAC if any adjustments must be made. See Transmittal 3364 and MLN Matters article MM9266 for further details.

Please contact Dominick Parris in the Department of Economics and Health Policy with your questions at .

In 2015, the CPT® codebook deleted breast ultrasound code and replaced it with two, more precise codes:

• 76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
• 76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited

Code 76641 describes a complete examination of all four quadrants of the breast and the retroareolar region; 76642 describes a limited breast ultrasound (e.g., a focused examination limited to one or more elements of 76641, but not all four). To support the service performed and billed, the provider should document a thorough exam of the anatomic area(s), and provide image documentation and a final, written report of results, impressions, etc.
Report 76641 or 76442 once, per breast, per session. Both codes are unilateral: If medical necessity requires bilateral imaging, you may append modifier 50 Bilateral procedure. The 2017 National Physician Fee Schedule Relative Value File assigns a “1” bilateral indicator to 76641 and 76442, meaning that Medicare will allow 150 percent of the standard reimbursement for properly billed bilateral procedures.
Both 76641 and 76442 include examination of the axilla, if performed. For ultrasound exam of the axilla, only, see 76882 Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific.

Example 1: Ultrasound exam of four quadrants of left breast and left axilla. Report 76641. Standard reimbursement applies.
Example 2: Complete ultrasound exam of left breast and right breasts (e.g., all four quadrants examined in both breasts): Report 76642-50. Code 76642 is reimbursed at 150 percent of fee schedule value for Medicare payers.
Example 3: Complete ultrasound exam of left breast, with ultrasound exam of two quadrants of the right breast: Report 76642-LT (complete exam of left breast) and 76641-RT (limited exam of right breast). Standard reimbursement applies.

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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

About John Verhovshek Has 570 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

Billing and Coding: CPT 2017 Updates Mammography Codes, but CMS Does Not
By Barbara Aubry, RN, CPC, CPMA, CHCQM, FABQAURP, and John Verhovshek, MA, CPC
Radiology Today
Vol. 18 No. 5 P. 6

For the past several years, proper coding for mammography services has depended on which payer the claim was filed with. The American Medical Association CPT codebook contained codes 77051 through 77057, which were accepted by most commercial payers. The Centers for Medicare & Medicaid Services (CMS), by contrast, required the use of dedicated G codes, created specifically for claims to Medicare payers. Unlike CPT codes 77051 through 77057, CMS G codes included computer-aided detection (CAD), when performed.

New Codes, Same Problem (for Now)
For 2017, CPT deleted codes 77051 through 77057 and introduced three new codes whose descriptors not only include CAD when performed but also exactly match those of the G codes required when reporting mammography to Medicare payers.
• 77065, Diagnostic mammography, including CAD when performed; unilateral.
• 77066, Diagnostic mammography, including CAD when performed; bilateral.
• 77067, Screening mammography, bilateral (two-view study of each breast), including CAD when performed.

In a perfect world, the new CPT codes would result in uniform coding of mammography services. But, due to technical issues, CMS was unable to ready its systems to process claims using CPT codes 77065, 77066, and 77067. As a result, mammography claims to Medicare in 2017 must continue to use G0202, G0204, and G0206.

Specifically, according to cms.org, CMS instructs that mammography be described using the following codes:
• G0202, Screening mammography, bilateral (two-view study of each breast), including CAD when performed.
• G0204, Diagnostic mammography, including CAD when performed; bilateral.
• G0206, Diagnostic mammography, including CAD when performed; unilateral.

Breast tomosynthesis is described using the following add-on codes:
• 77063, Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure).
• G0279, Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206).

When breast tomosynthesis is provided, practitioners should report one of G0202, G0204, or G0206 and one of G0279 or 77063. For purposes of billing digital breast tomosynthesis, the appropriate, accompanying 2D image(s) may either be acquired or synthesized.

The Bottom Line
In 2017, you'll continue to report mammography services for Medicare patients in the same way you reported them in 2015 and 2016. Use the G codes regardless of whether CAD was performed during mammography.

Note: CMS says it does intend to recognize the CPT codes 77065, 77066, and 77067—in place of the G codes—in 2018.

When reporting mammography services to non-Medicare payers who follow CPT guidelines, you should report new codes 77065–77067, which include CAD when performed.

To illustrate, consider the following examples:
• A Medicare patient undergoes a screening mammogram without tomosynthesis. Report G0202.
• A Medicare patient undergoes a screening mammogram and screening tomosynthesis. Report G0202 and 77063.
• A Medicare patient undergoes a diagnostic mammogram. Report either G0204 (bilateral) or G0206 (unilateral). If tomosynthesis is also ordered, report G0279 in addition to either G0204 or G0206, as appropriate.
• A patient with commercial insurance undergoes a screening mammogram. This payer follows CPT guidelines. Report 77067. If screening tomosynthesis is ordered and performed, also report 77063.
• A patient with commercial insurance undergoes a screening mammogram and screening tomosynthesis. This payer follows CPT guidelines. Report 77067 and 77063.
• A patient with commercial insurance undergoes a diagnostic mammogram. This payer follows CPT guidelines. Report either 77065 (unilateral) or 77066 (bilateral), depending on the order. If diagnostic tomosynthesis is provided, also, add G0279.

— Barbara Aubry, RN, CPC, CPMA, CHCQM, FABQAURP, is a senior regulatory analyst for 3M Health Information Systems.

— John Verhovshek, MA, CPC, is managing editor for AAPC.

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