CPT code 76642 is for a limited ultrasound of the breast, focusing on a specific area to assess abnormalities or guide procedures.
CPT code 76642 is used to describe a limited ultrasound examination of the breast. This procedure involves using sound waves to create images of a specific area of the breast, rather than a comprehensive scan of the entire breast. It is typically performed to evaluate a particular concern or follow up on a previously identified issue, such as a lump or abnormality detected in a prior exam. This targeted approach allows healthcare providers to focus on a specific area of interest, providing detailed information that can aid in diagnosis and treatment planning.
When dealing with CPT codes 76641 and 76642, which pertain to ultrasound procedures, certain modifiers may be applicable depending on the specific circumstances of the service provided. Below is a list of potential modifiers that could be used with these codes, along with the reasons for their application:
1. Modifier 26 (Professional Component): This modifier is used when only the professional component of the service is being billed. It indicates that the provider is billing for the interpretation of the ultrasound results, not the technical component.
2. Modifier TC (Technical Component): This modifier is applied when only the technical component of the service is being billed. It signifies that the provider is billing for the use of the equipment and the performance of the ultrasound, excluding the interpretation.
3. Modifier 50 (Bilateral Procedure): If the ultrasound is performed on both breasts during the same session, this modifier is used to indicate a bilateral procedure.
4. Modifier 76 (Repeat Procedure by Same Physician): This modifier is used if the same provider performs a repeat ultrasound on the same day for the same patient. It indicates that the procedure was repeated for a valid medical reason.
5. Modifier 77 (Repeat Procedure by Another Physician): Similar to Modifier 76, this is used when a repeat procedure is performed on the same day but by a different provider.
6. Modifier 59 (Distinct Procedural Service): This modifier is used to indicate that the ultrasound procedure is distinct or independent from other services performed on the same day. It is often used to bypass National Correct Coding Initiative (NCCI) edits.
7. Modifier 52 (Reduced Services): If the ultrasound service is partially reduced or eliminated at the discretion of the provider, this modifier is used to indicate that the service was not performed in its entirety.
8. Modifier 53 (Discontinued Procedure): This modifier is used when a procedure is started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
9. Modifier 22 (Increased Procedural Services): If the ultrasound procedure required significantly more effort than typically required, this modifier can be used to indicate the increased complexity or time involved.
These modifiers help provide additional information about the service rendered and ensure accurate billing and reimbursement. It is crucial to apply the appropriate modifiers based on the specific circumstances of the ultrasound procedure to avoid claim denials or delays.
The CPT code 76642 is subject to reimbursement considerations under Medicare, and its reimbursement status can be determined by consulting the Medicare Physician Fee Schedule (MPFS). The MPFS provides a comprehensive list of services and their corresponding reimbursement rates, which are updated annually. To ascertain whether CPT code 76642 is reimbursed by Medicare, healthcare providers should refer to the MPFS for the current year.
Additionally, it is important to consider the role of Medicare Administrative Contractors (MACs) in the reimbursement process. MACs are responsible for processing Medicare claims and can provide region-specific guidance on coverage and reimbursement policies. Since MACs may have local coverage determinations (LCDs) that affect the reimbursement of certain CPT codes, it is advisable for healthcare providers to check with their respective MAC for any specific guidelines or requirements related to CPT code 76642.
In summary, while the MPFS serves as a primary resource for understanding Medicare reimbursement rates, consulting with the relevant MAC is crucial for obtaining precise and localized information regarding the reimbursement of CPT code 76642.
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