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What needs to be imaged and documented in order to report code 76641 for a complete breast ultrasound?
In order to report code 76641 for a complete breast ultrasound, all four quadrants of the breast need to be imaged and documented as well as the retroareolar region. If all four quadrants and the retroareolar region are not imaged and documented in the report, it would be considered a limited exam and coded with 76642. Note that codes 76641 and 76642 also include imaging of the axilla, when performed. If imaging of the axilla is done with a complete or limited breast ultrasound, it may not be separately reported.
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