AMA Clinical Examples in Radiology - 2008 Issue 4 (Fall)
Radiology Test Case Answer
Radiology Test Case Answer (See page 6 for test case) 76645 Ultrasound breast(s) (unilateral or bilateral), real-time with image documentation Discussion Although the breast ultrasound was used for breast mass localization and not for more common diagnostic purposes, and the indication listed is for a more restrictive study than typically performed, it is nonetheless appropriate to code this study as a diagnostic breast ultrasound using code 76645 . The principle of coding this procedure is analogous to using ultrasound to mark a pleural effusion or ascites for aspiration by a nonradiologist physician. All requirements for reporting this as a diagnostic...
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Article Overview
This radiology coding article reviews a breast ultrasound test case and discusses how the study is characterized for reporting purposes. It also summarizes related guidance on documentation, image retention, and the use of assessment frameworks referenced by radiology organizations and CPT support materials. The article is relevant to coders, radiology staff, and compliance personnel working with breast ultrasound services.
Why This Topic Matters
Accurate identification of the service type and associated reporting expectations affects radiology coding, documentation compliance, and audit readiness for breast ultrasound studies.
Article Sections
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Discussion
This section discusses the breast ultrasound test case and the general context for reporting the service. It also references broader documentation and imaging expectations discussed by professional guidance sources.
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Coding Tip
This section provides general coding and reporting reminders tied to breast ultrasound examinations. It references assessment and documentation considerations mentioned in radiology guidance.
What You Will Learn
- How the article frames a breast ultrasound coding case
- What general documentation expectations are discussed for diagnostic ultrasound studies
- Which professional guidance sources are referenced in connection with breast ultrasound reporting
- What broad reporting considerations are highlighted for breast ultrasound examinations
Who Should Read This
- Medical coders
- Radiology coders
- Radiology department staff
- Compliance staff
- Auditors
Codes Discussed
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