CPT Code 76536: Ultrasound, Soft Tissues of Head and Neck

What is soft tissue ultrasound of the head/neck?

CPT code 76536 refers to a non-invasive imaging procedure that uses high frequency sound waves to perform an ultrasound examination of the soft tissues in the head and neck region. Healthcare providers commonly use this procedure to evaluate abnormalities such as thyroid nodules, lymph nodes, salivary glands, parathyroid lesions, or a palpable mass.

The ultrasound is typically performed in real-time, using a transducer placed over the skin to create gray-scale images of structures like the thyroid gland or parotid gland. It plays a critical role in monitoring known conditions, guiding biopsies, or assessing new symptoms such as swelling, lumps, or pain in the neck. As a first-line imaging tool, it provides a comprehensive evaluation without radiation exposure, making it ideal for follow-up and routine surveillance. Proper documentation, including the service performed, structures evaluated, and use of an appropriate modifier (if bilateral), is essential for billing, especially when submitting claims to Medicare or private payers.

CPT code 76536 documentation requirements

To ensure proper billing and compliance when reporting CPT code 76536, healthcare providers must include the following key documentation elements:

• Clinical indication: Clearly state the reason for the ultrasound examination, such as evaluating a lump, swelling, or thyroid nodules.
• Anatomical region scanned: Specify that the head and neck soft tissues were examined, including any focus on the thyroid gland, parathyroid, or lymph nodes.
• Structures evaluated: Document the soft tissues assessed and any relevant abnormalities, masses, or fluids identified.
• Procedure details: The noninvasive imaging procedure was performed using high-frequency sound waves, a real-time scan, and grayscale images.
• Service performed: Include the type of ultrasound (e.g., complete vs. limited), the transducer used, and the patient’s position on the examination table.
• Interpretation and findings: Provide a complete physician report summarizing the findings, diagnostic impressions, and any recommended follow-up.
• Bilateral procedures: If both sides of the neck were examined, apply the appropriate modifier and indicate it clearly in the report.
• Provider details: Confirm that a qualified provider or physician performed and interpreted the service.
• Progress monitoring: If applicable, describe how the scan monitors known conditions or assesses progress.

CPT code 76536 billing guidelines

Proper billing of CPT code 76536 ensures accurate reimbursement for the non-invasive imaging procedure used to evaluate soft tissues of the head and neck using high-frequency sound waves. This ultrasound examination is billed per study, not per structure (e.g., thyroid gland, lymph nodes, or parotid), regardless of how many structures are evaluated within the exam.

Key billing guidelines include:

• Billed once per study: Whether the ultrasound assesses one or multiple structures, the 76536 CPT code is only billed once per session.
• Do not report duplicate services: Avoid reporting a separate thyroid-specific ultrasound if CPT code 76536 already captures the thyroid gland as part of the comprehensive evaluation.
• Use appropriate modifiers: Modifier -26 for the professional component (physician interpretation), Modifier -TC for the technical component (equipment and technician), or apply a bilateral modifier only when the procedure is performed on both sides and supported by documentation.
• Support with ICD-10 codes: The billed service must align with the clinical indication, such as swelling, lump, thyroid nodules, or known conditions requiring follow-up or monitoring.
• Ensure documentation consistency: Match the images created, structures evaluated, and the report submitted with the appropriate billing details.
• Avoid unbundling: Do not separately bill for imaging of structures like the thyroid or parathyroid if they’re already included in the head and neck scan.

Following these billing rules helps healthcare providers and medical offices maintain compliance, reduce claim denials, and ensure they are adequately paid for the service performed under Medicare and other payer contracts.