CPT 76642Radiology

Ultrasound breast limited

CPT code 76642 is for a limited ultrasound examination of the breast, which uses sound waves to create images of a specific area of concern in breast tissue rather than examining the entire breast.

Showing rates for

National Average

Base Medicare rate

$82.16

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

0.68

PE RVU (NF)

1.81

MP RVU

0.05

Total RVU

2.54

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

NCCI bundling edits

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Billing tips

Always append RT or LT modifier to specify laterality, as many payers require this for breast imaging codes and will deny claims without anatomical designation
Impact: Prevents initial denials and resubmission delays that can extend payment cycles by 30-45 days
Document the specific quadrant or area examined and the clinical indication (palpable mass, mammographic finding) to distinguish from complete breast ultrasound (76641)
Impact: Reduces downcoding risk from 76642 ($82.16) to unlisted or denied claims; proper documentation supports full reimbursement
Do not bill 76642 with 76641 or 76645 for the same breast on the same date of service unless distinct areas are examined with modifier 59
Impact: Avoids bundling denials and potential audit flags; unbundling violations can result in 100% claim denial
Ensure the written report includes real-time imaging documentation, measurements of any abnormalities, and comparison to prior studies when available
Impact: Meets Medicare documentation requirements and reduces post-payment audit recoupment risk
Bill global service (no modifier) when performed in non-facility settings where you own the equipment and provide interpretation
Impact: Maximizes reimbursement at full $82.16 rate versus split billing which divides payment between 26 and TC components
Verify that the ordering physician documented medical necessity in the patient's chart before the ultrasound was performed
Impact: Protects against medical necessity denials and ensures compliance with Protecting Access to Medicare Act (PAMA) requirements

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 76642 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 76642 is $82.16 for both facility and non-facility settings, based on the CMS Physician Fee Schedule with a conversion factor of 32.3465.

What is the difference between CPT 76642 and 76641?

CPT 76642 is a limited breast ultrasound focused on a specific area or quadrant, while CPT 76641 is a complete unilateral (one breast) ultrasound examining all four quadrants. The limited exam (76642) is typically performed to evaluate a specific clinical finding, whereas the complete exam (76641) provides comprehensive assessment of the entire breast.

Do I need a modifier for CPT code 76642?

Yes, CPT 76642 typically requires a laterality modifier (RT for right breast or LT for left breast). Additionally, you may need modifier 26 for professional component only, TC for technical component only, or 59 if performed as a distinct service on the same day as other breast imaging.

How many RVUs is CPT code 76642 worth?

CPT 76642 has a total of 2.54 RVUs for 2025, consisting of 0.68 work RVUs, 1.81 practice expense RVUs (both facility and non-facility), and 0.05 malpractice RVUs according to CMS Medicare Physician Fee Schedule RVU25A.

Can CPT 76642 be billed bilaterally?

CPT 76642 represents a unilateral limited exam, so if limited ultrasounds are performed on both breasts, you would bill 76642-RT and 76642-LT separately. However, verify payer-specific policies as some may require different coding or have specific bilateral billing rules for limited breast ultrasounds.

What diagnosis codes support medical necessity for CPT 76642?

Common supporting diagnosis codes include R22.0-R22.9 (localized swelling, mass and lump), N63.XX (unspecified lump in breast with laterality), R92.8 (other abnormal mammogram findings), and N64.4 (mastodynia/breast pain). The diagnosis must indicate a specific clinical finding warranting focused ultrasound rather than screening.

Can I bill CPT 76642 with a breast biopsy on the same day?

Yes, you can bill 76642 with breast biopsy codes when the ultrasound is used for a diagnostic evaluation separate from the biopsy guidance. However, if the ultrasound is solely for biopsy guidance, report the appropriate ultrasound guidance code (76942) instead. Use modifier 59 on 76642 if billing both services to indicate the diagnostic ultrasound was a distinct service from the biopsy procedure.