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2025 CPT code 76641

Complete ultrasound of one breast, including image documentation and axilla if performed.

* A complete ultrasound examination includes all four quadrants, the retroareolar region, and the axilla (if performed).* If less than a complete exam is performed, code 76642 should be used.* Separate codes exist for evaluation of vascular structures using Doppler.* Permanently recorded images and a written report are required.

Modifiers 26 (professional component) and TC (technical component) may apply depending on the billing arrangement and payer policies.

Medical necessity for a complete breast ultrasound (76641) is established by the presence of symptoms (e.g., palpable lump, pain, abnormal mammogram findings), family history, or other clinical indicators warranting a comprehensive evaluation of breast tissue and related axillary structures.

The physician or qualified healthcare professional performs the ultrasound examination using a transducer to produce images of the breast tissue and the axillary region (if applicable). Interpretation of the images and creation of a written report are part of the clinical responsibility.

IMPORTANT:76642 (limited ultrasound of one breast)

In simple words: This test uses sound waves to create pictures of the inside of one breast. The pictures show the entire breast and the armpit area if needed. The doctor will make sure to get all the images they need, and then will write a report about the test.

This CPT code represents a complete real-time ultrasound examination of one breast.The examination includes imaging of all four quadrants of the breast and the retroareolar region.It also encompasses ultrasound examination of the ipsilateral axilla if performed.The procedure requires permanently recorded images with measurements, when clinically indicated, and a final written report.

Example 1: A patient presents with a palpable breast lump. A complete breast ultrasound (76641) is ordered to evaluate the lump and surrounding tissue, including the axilla for any possible lymph node involvement., A patient is recalled for further investigation following an abnormal mammogram.A complete breast ultrasound (76641) is performed to assess the areas of concern and delineate the extent of any abnormality., A patient presents with breast pain. A complete breast ultrasound (76641) is ordered to rule out any underlying pathology, including evaluation of the axilla to assess for lymphadenopathy.

* Detailed clinical history and reason for the examination.* Permanently recorded images with measurements (when clinically indicated).* Final written report including description of all four quadrants, retroareolar region, and axilla (if performed).* Documentation of any abnormalities, and reasons for non-visualization of elements.

** The use of ultrasound without thorough evaluation, image documentation, and a final written report is not separately reportable.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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