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76641

Complete Breast Ultrasound

Code Description

CPT code 76641 is used to report a complete ultrasound examination of one breast. A complete examination includes all four quadrants of the breast and the retroareolar region; examination of the axilla is included when performed.

The code is reported per breast. A complete breast ultrasound may be used to further evaluate breast tissue or as supplemental imaging when medically appropriate.

When to Use 76641

Common examples include:

  • Complete ultrasound evaluation of one breast

  • Evaluation of breast tissue abnormalities

  • Supplemental imaging of dense breast tissue when medically appropriate

  • Further evaluation following other breast imaging

  • Complete assessment of breast quadrants and the retroareolar region

Documentation Requirements

Documentation should include:

  • Reason for the examination

  • Breast examined

  • Complete examination of the required breast regions

  • Relevant symptoms or imaging findings

  • Image documentation

  • Final written interpretation and report

Common Billing Mistakes

Common billing mistakes include:

  • Reporting 76641 for a limited breast ultrasound

  • Failing to document a complete examination

  • Assuming the code represents both breasts

  • Incorrectly reporting bilateral services

  • Insufficient documentation of medical necessity

Related CPT Codes
77065

Diagnostic Mammogram, One Breast

77066

Diagnostic Mammogram, Both Breasts

77067

Screening Mammogram, Both Breasts

FAQ

What does CPT code 76641 cover?

CPT code 76641 reports a complete ultrasound examination of one breast. A complete exam includes all four quadrants and the retroareolar region.

Is CPT 76641 reported for one breast or both breasts?

CPT 76641 is reported per breast. Bilateral reporting depends on payer requirements and may involve Modifier 50 or separate RT and LT reporting.

What is the difference between CPT 76641 and 76642?

CPT 76641 represents a complete breast ultrasound, while CPT 76642 represents a limited or focused breast ultrasound examination.

Can CPT 76641 be used with mammography codes?

Breast ultrasound and mammography are different imaging services. When both are medically necessary and properly documented, they may be reported according to applicable coding and payer requirements.

Procedure Type

Diagnostic Ultrasound

Body Area

Exam Type

Breast

Complete