Proper Ultrasound Coding for Soft Tissues of the Head

Ultrasound codings can be daunting for some medical billers. It can be confusing to narrow down the exact nature of the procedure and to provide the documentation to show the necessity of an ultrasound, no matter what the results were.

When reporting a procedure such as an ultrasound of a patient’s lip, you will need to be certain that the appropriate code, which is 76536 (Ultrasound, soft tissues of head and neck [e.g., thyroid, parathyroid, parotid], B-scan, and/or real time with image documentation) is used.

Code 76536 describes a B-scan ultrasound of the soft tissues of the head and neck. A B-scan is a “two-dimensional ultrasonic scanning procedure with a two-dimensional display,” according to CPT.

The confusion comes when many medical billers choose to use CPT code 76999 (Unlisted ultrasound procedure [e.g., diagnostic, interventional]) for the lip exam and that may result in a denial or partial payment of the claim from a carrier that wants to see the 76536 CPT code used for such claims.

You can avoid a lot of hassles and confusion in your coding if you outsource your medical billing to a third party partner, who will not only have the most current information on what coding to use to get maximum reimbursements, you will even receive a faster turnaround on your claims due to their filing methods!

View all Articles by: Melissa Clark, CCS-P