Radiology Question for the Week of January 25, 2016

Question:

Question 

We received an order from a referring physician that requested an ultrasound (US) thyroid for nodule assessment and an US soft tissue for a submental mass palpable on exam.  The facility coder believes that the facility should get two charges.  The interpretation covers both areas in one report.  It is my understanding that US head and neck (CPT 76536) would cover both of these assessments. Am I correct?  The evaluation is performed for two separate reasons, but the imaging is of the neck.    

Answer

It is one code, 76536, and it is assigned only once. With few exceptions (such as diagnostic and screening mammograms), CPT codes are not differentiated by clinical indication. Code 76536 includes all ultrasound imaging of soft tissues of the head and/or neck regardless of the reason or reasons. 

76536 Ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation

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