CPT 76513Radiology

Oph us dx ant sgm us uni/bi

CPT 76513 covers an ultrasound examination of the front part of the eye (the anterior segment), which includes structures like the cornea, iris, and lens. This specialized imaging helps doctors evaluate eye conditions that may not be visible through standard examination.

Showing rates for

National Average

Base Medicare rate

$72.13

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

0.6

PE RVU (NF)

1.61

MP RVU

0.02

Total RVU

2.23

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Verify whether the procedure was unilateral or bilateral and document accordingly, as 76513 includes both scenarios in a single code
Impact: Prevents duplicate billing errors that could result in audits; ensures proper coding without modifier 50
Always append RT or LT modifier when only one eye is examined to meet payer-specific anatomic modifier requirements
Impact: Reduces claim rejections by 15-25% with major payers requiring eye-specific laterality modifiers
Separately document and bill E/M service with modifier 25 when significant separately identifiable evaluation occurs on same day
Impact: Can add $75-$200 in additional reimbursement when properly documented with distinct diagnosis or medical decision-making
Link appropriate ICD-10 codes for angle closure (H40.2x), hyphema (H21.0), or lens subluxation (H27.1x) to support medical necessity
Impact: Reduces denial rate by approximately 30%; specific diagnosis codes justify imaging when direct visualization impossible
Do not bill 76513 with 92020 (gonioscopy) on the same day without modifier 59 and clear documentation of medical necessity for both
Impact: Prevents bundling denials and potential $72.13 payment loss; modifier 59 with documentation supports separate reimbursement
Ensure written interpretation and report is completed and signed before claim submission, stored in patient record for audit defense
Impact: Critical for audit protection; missing reports are primary cause of recoupment in 40% of ophthalmic ultrasound audits

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Frequently asked questions

What is the 2025 Medicare reimbursement rate for CPT code 76513?

The 2025 Medicare national average reimbursement for CPT 76513 is $72.13 for both facility and non-facility settings. This is based on a total RVU of 2.23 (Work RVU 0.6, PE RVU 1.61, MP RVU 0.02) multiplied by the 2025 conversion factor of 32.3465.

Does CPT 76513 include both eyes or just one eye?

CPT 76513 is a unilateral or bilateral code, meaning it covers examination of one eye OR both eyes with a single code. You should not use modifier 50 for bilateral procedures. Use RT or LT modifiers when only one eye is examined to specify laterality.

Can I bill an E/M visit and 76513 on the same day?

Yes, you can bill an evaluation and management service with CPT 76513 on the same day if there is a significant, separately identifiable service provided. Append modifier 25 to the E/M code and ensure documentation clearly shows the separate nature of the evaluation beyond the decision to perform the ultrasound.

What modifiers are commonly used with CPT 76513?

Common modifiers for 76513 include RT/LT (right/left eye specification), 26 (professional component only), TC (technical component only), and 59 (distinct procedural service when billed with other procedures). Modifier 50 should NOT be used as the code already encompasses bilateral examination.

What documentation is required to bill CPT 76513?

Required documentation includes the clinical indication for the ultrasound, which eye(s) were examined, ultrasound technique and parameters, specific structures evaluated, measurements obtained, abnormal findings with descriptions, clinical correlation, and a signed physician interpretation report. Missing reports are a primary cause of denials.

What ICD-10 codes are commonly used with CPT 76513?

Common diagnosis codes include H40.2x (acute angle-closure glaucoma), H21.0 (hyphema), H27.1x (lens subluxation/dislocation), D31.4x (ciliary body neoplasm), H16.x (keratitis with corneal opacity), and S05.x (ocular trauma). The diagnosis must support why ultrasound was medically necessary.

Can CPT 76513 be billed with gonioscopy (92020) on the same day?

Billing 76513 with 92020 on the same day requires careful documentation and typically modifier 59 on 76513 to show distinct procedural service. You must document separate medical necessity for both angle assessment methods, such as using gonioscopy first but requiring ultrasound due to poor visualization or need for quantitative measurements.