Ultrasound scans can be tricky to bill. Complex documentation and confusing modifier usage make the billing of these procedures challenging. On top of this, clear billing instructions and guidelines are also scarce for ultrasound procedures.
A frequently used imaging code is CPT code 76536. Despite its frequent use, many billers struggle to file it correctly. That’s why we have created this detailed guide on 76536, so you don’t have to face denials anymore. Let’s start.
CPT Code 76536 – Description
CPT code 76536 is defined as:
“Ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real-time with image documentation.”
Code 76536 is a diagnostic code. It is used for ultrasound imaging in radiology practices and laboratories. The procedure is used to create detailed images of the head and neck soft tissues, like the thyroid, parathyroid, and parotid glands.
Please note that, like most diagnostic ultrasound procedures, 76536 is also a non-invasive technique. Plus, it involves real-time imaging and image documentation. It helps providers diagnose several conditions without any complications.
Scenarios Where CPT Code 76536 is Applicable
In order to understand the effective use of CPT code 76536, let’s look at some scenarios in which it can be used:
Malignant Neoplasm of the Thyroid Gland
Let’s take an example of a cancer patient. Imagine that a 50-year-old patient visits his physician. He has a lump in his neck and experiences difficulty swallowing. The patient also has a family history of thyroid disorders. During the checkup, the physician suspects that a malignant neoplasm in the thyroid gland (thyroid cancer) is causing the visible symptoms.
However, to confirm his suspicion, the physician orders an ultrasound of the neck and head. The results show a suspicious mass around the thyroid. This points to a higher possibility of malignant neoplasm of the thyroid gland. In this scenario, CPT code 76536 will be used to report the ultrasound. However, further testing and a biopsy will be needed to confirm the cancer diagnosis.
Nontoxic Diffuse Goiter
Imagine that a patient with neck swelling, tightness, and mild difficulty breathing visits a primary care physician. The patient is between 30 and 40 years of age and has a family history of endocrine issues. The attending physician suspects that a nontoxic diffuse goiter is enlarging the thyroid gland and causing the visible symptoms.
A head and neck ultrasound is ordered for confirmation. The physician uses real-time imaging to assess the thyroid gland and surrounding tissues, and the results indicate uniform enlargement without nodules. The ultrasound in this case can be billed using CPT code 76536.
Applicable Modifiers for CPT Code 76536
The following are some modifiers that can be appended to CPT code 76536:
| Modifier | Description | Clinical Application |
|---|---|---|
| TC | Technical Component | Used for technical aspects, including equipment use, technician’s time, and supplies. |
| 26 | Professional Component | Used when the provider only interprets the images obtained by another facility or bills separately for interpretation and reporting. |
| 52 | Reduced Services | Used when ultrasound examination is partially reduced or limited due to patient factors or clinical circumstances. |
| 76 | Repeat Procedure by Same Physician | Applies when the same physician repeats the ultrasound procedure on the same day due to clinical necessity. |
| 77 | Repeat Procedure by Another Physician | Indicates a different physician performed a repeat ultrasound on the same day. |
CPT Code 76536 – Billing & Reimbursement Guidelines
The difference between an accepted and denied claim often lies in small details. To help you avoid claim denials, we have provided some guidelines and vital information regarding CPT code 76536.
Documentation Requirements and Medical Necessity
For proper reimbursement, you must provide comprehensive documentation with your claims. The documentation helps support the medical necessity of the service and gives insurance payers a detailed picture of the circumstances in which the service was performed. For code 76536, the following documentation is necessary:
- The patient’s condition and symptoms
- Detailed image documentation
- Permanent image storage and retention
- Patient identification on all images
- Examination date and provider credentials
To justify the medical necessity of CPT code 76536, you must also use an appropriate ICD-10 code that validates the reasoning for the procedure. The following are some valid diagnosis codes:
- C47.0: Malignant neoplasm of peripheral nerves of head, face, and neck
- D09.8: Carcinoma in situ of other specified sites
- D34: Benign neoplasm of the thyroid gland
- D35.1: Benign neoplasm of the parathyroid gland
- E03.4: Atrophy of thyroid (acquired)
- E04.0: Nontoxic diffuse goiter
- E04.1: Nontoxic single thyroid nodule
You can find the complete list of ICD-10 codes that justify medical necessity for 76536 in the CMS guide.
Medicare Reimbursement Rates
The reimbursement amount for CPT code 76536 varies for each MAC locality. The national average reimbursement amount for 76536 is $106.10 in non-facility settings.
The following is a more detailed breakdown of the cost structure:
- Professional component:
- Facility price: $25.88
- Non-facility price: $25.88
- Technical component:
- Facility price: Not applicable
- Non-facility price: $80.22
You can check the exact reimbursement rate for your MAC locality via the PFS Lookup Tool.
Wrapping Up
Let’s wrap up everything. CPT code 76536 refers to an ultrasound procedure of the head and neck area. It is specifically used to image soft tissues and involves real-time imaging. For fair reimbursement, you must append the appropriate modifiers and documentation with your claims.
In this guide, we have tried our best to provide you with all the necessary information required to file 76536 claims successfully. However, if you are facing frequent denials and your revenue is decreasing, consider getting professional radiology billing services from specialized companies like MediBillMD.
