Ultrasound Breast Documentation Guidelines

Ultrasound Breast Coding and Documentation Tips graphic from Pure RCM Health

Breast ultrasound is a noninvasive diagnostic imaging technique that produces images used to assess breast tissues. Ultrasound uses a transducer that sends out ultrasound waves at a frequency too high to be heard. The ultrasound transducer is placed on the skin, and the ultrasound waves move through different densities of breast tissue. The sound waves bounce off the tissues like an echo and return to the transducer. The transducer processes the reflected waves, which are then converted by a computer into an image of the breast tissues being examined. Real time scanning displays structure images and movement with time. Report 76641 for a complete ultrasound, which includes examination of all four quadrants of the breast, as well as the retroareolar region. Report 76642 for a limited ultrasound, which pays particular attention to one or more, but not all, of the elements described by 76641. Examination of the axilla is included in both codes, when performed.

Coding Tip

If Bilateral breasts Ultrasound performed , use the code with modifier 50.

For axillary ultrasound only, see 76882. Utilization of ultrasound without evaluation of organs/region, image documentation, and written report is not reported separately.

Documentation Requirements

Complete US 76641

Complete Ultrasound breast should include,

  • All four quadrants of the breast  
  • Retro-areolar region 
  • Axilla (if performed)
  • Image of Ultrasound must be saved in patient medical record

Limited US 76642

Code 76642 consists of a focused ultrasound examination of the breast limited to the assessment of one or more, but not all of the elements listed in code 76641. It also includes ultrasound examination of the axilla, if performed.

  • Image of Ultrasound must be saved in patient medical record
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