Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
CPT4 code
Name of the Procedure:
Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
Common Names: Breast Ultrasound, Breast Sonogram
Summary
A breast ultrasound is an imaging procedure that uses high-frequency sound waves to produce real-time images of breast tissue. In a unilateral exam, only one breast is examined. The procedure also includes imaging of the axilla (armpit area) to check for any abnormalities in the lymph nodes.
Purpose
The primary goal of a breast ultrasound is to detect and assess abnormalities in breast tissue, such as lumps, cysts, or suspicious lesions. It aids in the diagnosis of breast conditions and helps guide treatment decisions.
Indications
- Presence of a breast lump or mass
- Unexplained breast pain or tenderness
- Abnormal results from a mammogram
- Follow-up evaluation of known breast abnormalities
- Assessment of breast implants
- Evaluation of lymph nodes in the axilla
Preparation
- No specific fasting or dietary restrictions
- Wear a two-piece outfit for convenience, as only the upper body needs to be exposed
- Remove any jewelry or accessories near the chest area
- Inform the technician of any prior breast surgeries or conditions
Procedure Description
- The patient will lie down on an examination table.
- A clear gel will be applied to the breast, which helps the ultrasound transducer glide smoothly and conduct sound waves into the tissue.
- The technician moves the transducer over the breast and axilla, capturing real-time images.
- The images are documented and reviewed by a radiologist.
- The procedure is generally painless and does not require anesthesia.
Duration
The procedure typically takes about 15–30 minutes.
Setting
The procedure is usually performed in a hospital radiology department or an outpatient imaging center.
Personnel
- Radiologic Technologist (Ultrasound Technician) performs the imaging
- Radiologist reviews and interprets the images
Risks and Complications
- No known risks as it does not use radiation
- Rare cases of discomfort from the pressure of the transducer
Benefits
- Non-invasive and painless
- Quick and provides immediate results
- Helps in accurate diagnosis and treatment planning
- Can assess conditions that mammograms might miss
Recovery
- No recovery time needed
- Patients can resume normal activities immediately after the procedure
- Follow-up with a healthcare provider to discuss the results
Alternatives
- Mammography: Uses low-dose X-rays for breast imaging
- MRI: Provides detailed images and is used in certain scenarios
- Breast biopsy: Involves removing a sample of tissue for laboratory analysis
Patient Experience
- Generally painless, though slight pressure may be felt from the transducer
- The gel may feel cold when first applied but is not uncomfortable
- No downtime required, and routine activities can be resumed immediately