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Coding for breast ultrasound and diagnostic mammography performed on the same day

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Q.

Can you provide any reporting guidance for the following scenario?

A patient comes in for a bilateral breast ultrasound and a diagnostic bilateral mammo with tomosynthesis. Due to suspicious findings, the patient is sent, on the same day, for a left breast ultrasound-guided core biopsy with micro clip placement and a post-procedural mammogram with tomosynthesis. We reported:

  • Ultrasound breast bilateral CPT® code 76642
  • Mammogram diagnostic bilateral with tomosynthesis CPT codes 77066 & 77062
  • Left breast ultrasound-guided core biopsy with micro clip placement CPT code 19083
  • Post-procedural mammogram with tomosynthesis CPT codes 77061 & 77065

The post-procedure mammogram and tomosynthesis produces a CCI edit as it is bundled with the original bilateral mammogram with tomosynthesis.

What is the guidance on the reporting of this scenario?

A.

The first issue I see is you are reporting code 76642 for a bilateral breast ultrasound. Code 76642 is for reporting a unilateral limited breast ultrasound. If you performed a bilateral breast ultrasound, you would need to add either modifier –50 or report with modifiers –RT and –LT depending on payer preference. You would do the same if you did a complete bilateral breast ultrasound – you would report 76641-50 or 76641-RT and 76641-LT. There is no single code to report a bilateral breast ultrasound.

Second, diagnostic mammography codes include any and all diagnostic breast mammographic imaging on the same day. So, if you did diagnostic imaging on the same day that you did a biopsy and post-procedure mammogram, the post-procedure mammographic images are included in the pre-procedure diagnostic mammogram. The code and full description are as follows:

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