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Official Description

Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

A unilateral breast ultrasound, designated by CPT® Code 76641, is a diagnostic imaging procedure that utilizes real-time ultrasound technology to visualize the breast and, when applicable, the axillary region. This procedure is particularly valuable in the assessment of breast abnormalities that may have been identified during a physical examination or through mammographic imaging. The ultrasound technique is adept at distinguishing between solid masses and fluid-filled cysts, as well as providing detailed information about the structural characteristics of the abnormal area and the surrounding breast tissue. During the examination, the patient is positioned supine, with the arm on the side being examined raised above the head to optimize access to the breast. Acoustic coupling gel is applied to ensure effective transmission of the ultrasound waves, and a transducer is placed firmly against the skin. The transducer emits ultrasonic wave pulses, which penetrate the breast tissue and are reflected back, creating images based on the echoes received. This comprehensive examination includes evaluation of all four quadrants of the breast, as well as the area directly behind the areola, to ensure a thorough assessment. The physician subsequently reviews the captured images and generates a written interpretation of the findings, which is crucial for determining the next steps in patient care.

© Copyright 2026 Coding Ahead. All rights reserved.

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