What distinguishes the two forms of elastography as described by CPT® codes 91200 and 0346T?
The distinguishing characteristic between the two forms of elastography (91200 Liver elastography; 0346T Ultrasound, elastography) is imaging.
There are ultrasound imaging systems that have built-in shear wave, as well as regular ultrasound imaging. When imaging-based shear wave elastography or acoustic force imaging is done using one of these systems, one should report the add-on Category III code 0346T in addition to the anatomy based primary ultrasound code. These systems use imaging guidance to define the shear wave or acoustic radiation force region of interest. The result is in the form of a parametric mapping of numeric values, therefore, an image.
To our knowledge there is only one FDA-approved system that does non-imaging elastography. The purpose is to examine the liver and determine the amount of fibrosis, not to evaluate lesion characteristics. The result is a value not an image. Category I code 91200 should be reported to describe this type of non-imaging liver elastography. It is incorrect to report 91200 to describe imaging-based elastography.
Both 91200 and 0346T could be done either before or after a formal liver ultrasound. However, when non-imaging shear-wave elastography testing is performed in conjunction with a formal liver ultrasound, it is recommended that a modifier (e.g., 59) be used to designate this as a separate and distinct procedure.
Now that there are two new breast ultrasound codes (Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete (76641), and limited (76642)), should referring physicians be asked to specify on the order whether they want limited or complete, or should the radiologist do what they think is appropriate no matter what is on the order?
The referring physician does not need to specify in an order if a complete or limited breast ultrasound is required. The type of ultrasound performed may be determined by the radiologist under the Ordering of Diagnostic Test Rule exemption, similar to the decision to perform a CT with or without contrast. For example, if the order is for breast ultrasound, the radiologist may determine if it should be a complete or limited ultrasound based on the medical necessity. However, if the referring physician specifies that a complete or limited ultrasound should be performed, the radiologist should speak with the referring physician if the radiologist disagrees with the type of study requested.
As noted above, the determination of whether a complete or limited study is performed falls under the Ordering of Diagnostic Tests Rule exemption, i.e., Unless specified in the order, set the protocol for a given diagnostic, interventional, or therapeutic procedure ordered (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media) (see Section 80.6, Chapter 15, Pub. 100-02 of the internet-only Medicare Benefit Policy Manual).
What makes up a limited and a complete breast ultrasound?
Per the CPT 2015 codebook, Professional Edition, p. 428, code 76641 represents a complete ultrasound examination of the breast. Code 76641 consists of an ultrasound examination of all four quadrants of the breast and the retro-areolar region. It also includes ultrasound examination of the axilla, if performed.
Code 76642 consists of a focused ultrasound examination of the breast limited to the assessment of one or more, but not all of the elements listed in code 76641. It also includes ultrasound examination of the axilla, if performed.
Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final written report, is not separately reportable.
If the same breast ultrasound study is performed on both breasts, how should that be coded?
The newly created breast ultrasound codes are unilateral procedures. When the same type of breast ultrasound study is performed on both breasts, it is appropriate to report the code twice – once with an RT modifier and once with an LT modifier to designate a bilateral procedure was performed. For example, a complete breast ultrasound of both the right breast and left breast would be reported as 76641-RT and 76641-LT. As modifiers are payer specific, check with your third party payers to determine how you should report these procedures.