Question:

We received an order from a referring physician that requested an ultrasound (US) thyroid for nodule assessment and a US soft tissue for a submental mass palpable on the 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 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.

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