Coding Corner: Breast imaging coding changes in 2015

March 01, 2015
Area(s) of Interest: Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.   

The CPT® 2015 codebook deleted a familiar breast ultrasound code (76645), while adding two new, more precise codes to describe the same procedure. 

  • 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.

You may report either 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 2015 National Physician Fee Schedule Relative Value File (January release) 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.

Also new to CPT® 2015 are three codes to describe digital breast tomosynthesis (DBT).

  • 77061 Digital breast tomosynthesis; unilateral

  • 77062 Digital breast tomosynthesis; bilateral

  • 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)

Codes 77061 and 77062 define unilateral and bilateral diagnostic DBT, respectively. Do not report either code with 76376 or 76377 (3-D rendering), or 77057 (screening mammography).

Code 77063 is an add-on code, to be reported with 77057 Screening mammography, bilateral (2-view film study of each breast) (or G0202 Screening mammography, producing direct digital image, bilateral, all views, when billing Medicare) for (bilateral) screening DBT. Do not report 77063 with 76376 or 76377 (3-D rendering), or 77055 or 77056 (Mammography).

The Centers for Medicare and Medicaid Services (CMS) announced in its 2015 Medicare Physician Fee Schedule Final Rule that 77061 and 77062 (diagnostic DBT) are not valid for Medicare billing. Instead, providers should report diagnostic DBT to Medicare using HCPCS code G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206).

Note that G0279 is an add-on code, which you must report with either G0204 Diagnostic mammography, producing direct digital image, bilateral, all views or G0206 Diagnostic mammography, producing direct digital image, unilateral, all views, as appropriate, for tomosynthesis with diagnostic digital mammography. Because CMS will not accept the stand-alone diagnostic DBT codes (77061 and 77062), providers have no way to report diagnostic DBT to Medicare, separate from a full-field digital mammogram. 


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