Current Coding Practices for Certain Breast Ultrasound Services

Reimbursement coding is a function of the facts and circumstances in each patient encounter. The following information provides neither coding advice nor identification of a “correct” coding approach. Instead, the sole purpose of this information is to serve as an educational resource for providers. Providers are solely responsible for identifying the codes that describe their services.
The principal research method for the information contained in this section was the conduct of structured telephone interviews with health care providers – freestanding breast-imaging centers and private physician practices. To supplement the interviews, U-Systems contracted with medical reimbursement advisors to review benefits and coverage materials from a sample of health insurers. 
The descriptors for the two codes are as follows:
  • CPT 76645: “Ultrasound, breast(s) (unilateral or bilateral), with real time with image documentation.”
  • CPT 76377: “3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation.” 
Both codes can be used to describe breast ultrasound services. The American Medical Association, which develops and administers CPT codes, recognizes no blanket restriction on reporting the two codes for the same case – CPT 76645 (“76645”) for a base breast ultrasound diagnostic procedure, and CPT 76377 (“76377”) for a complex rendering. Nevertheless, this is distinct from coverage and payment policies that are set by individual health benefit plans.
In general, U-Systems' advisors found few coverage policies that addressed CPT code 76377 explicitly and individually. Only one private insurer in our sample had a written policy that specifically identified 76377 services as not payable.
Some insurers applied bundling or pre-authorization policies to broader categories of ultrasound or imaging services, thus affecting - but not uniquely - breast ultrasound services described by 76377.   

Important Note:  U-Systems, Inc., and its contractor obtained this reimbursement information from third-party sources, and U-Systems provides it here for illustrative purposes only.  This information cannot cover all situations or third-party payors’ rules or policies.  The information cannot guarantee coverage or reimbursement, and U-Systems, Inc., makes no other representations or warranties as to selecting codes for procedures or compliance with any other billing protocols or prerequisites.  As with all claims, individual physicians and hospitals are responsible for exercising their independent clinical judgment in selecting the codes that most accurately reflect the patient’s condition and procedures performed for a patient.  Laws, regulations, and policies concerning `coding and reimbursement are complex and are subject to change.  Physicians and hospitals should refer to current, complete, and authoritative publications such as AMA CPT lists, Medicare bulletins or program memoranda, or third-party payor policies for selecting codes based on the care rendered to an individual patient, and may wish to contact individual carriers, fiscal intermediaries, or other third-party payers as needed.