L29328-LCD

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Local Coverage Determination (LCD) for Screening and Diagnostic Mammography (L29328)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29328

LCD Title

Screening and Diagnostic Mammography

Contractor's Determination Number 77055

Primary Geographic Jurisdiction opens in new window

Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 11/04/2010

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources:

. Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical checkups.

. Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury.

. Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

. 21 CFR part 900, subpart B. This section implements FDA certification requirements for suppliers of mammography services.

. Balanced Budget Act of 1997, Section 4101. This section provides coverage for annual screening mammograms for all women age 40 and over and waives the Part B deductible for screening mammography.

CMS Manual System, Pub 100-02, Medicare Benefit Manual, Chapter 15, §208.3

CMS Manual System, Pub 100-03, Medicare National Determination Manual, Chapter 1, Part 4, §220.4 CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 18, §20

Indications and Limitations of Coverage and/or Medical Necessity

Screening Mammogram

A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection breast cancer, or a personal history. A screening mammogram does not require a physician’s referral, however, detection of a radiographic abnormality, may prompt the interpreting radiologist to order additional views on the same day. When this is the case, the mammography is no longer considered to be a screening exam and should be reported as a diagnostic mammogram. Radiologists who order additional tests must refer back to the treating physician or qualified non-physician practitioner for his/her UPIN and report back to the treating physician the condition of the patient. No separate reimbursement will be made for additional views. The cost for additional views is included in the cost of the diagnostic mammography service. Medicare beneficiaries are allowed screening mammogram(s) (digital and non-digital) for the following indications:

• Women ages 40 and older are eligible to receive a screening mammogram (digital and non digital) every 12 months

• Women with Medicare between the ages of 35 and 39 are eligible to received one baseline mammogram Services will only be allowed if supplied by certified suppliers or FDA-certified mammography centers. Limitations

• The mammogram must consist of at least a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast.

• Screening mammograms are not allowed on women under age 35.

• Screening mammograms performed prior to 11 months lapsing following the month in which the last screening mammography service was rendered is noncovered.

• Facilities that perform screening mammography services may not release screening mammography x-rays for interpretation to physicians who are not approved under the facility’s certification number unless the patient has requested a transfer of the films from one facility to another for a second opinion or the patient has moved to another part of the country where the next screening mammography will be performed.]

Diagnostic Mammography

A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician’s interpretation of the results of the procedure.

Medicare will allow diagnostic mammogram(s) for the following indications:

- the patient is under the care of the referring/ordering physician or qualified non-physican practitioner;

- there are signs and/or symptoms suggestive of malignancy (mass, some types of spontaneous nipple discharge or skin changes);

- there are possible radiographic abnormalities detected on screening mammography;

- there is short interval follow-up (less than one year) necessary for unresolved clinical/radiographic concerns; or

- follow-up of established history of a malignancy is necessary

Diagnostic breast evaluation may be indicated in cases of a personal history of malignancy and in cases of benign biopsy-proven breast disease. These diagnoses should not, however, routinely warrant a diagnostic mammography.

A breast implant does not necessarily imply that a mammogram is diagnostic in nature. Although additional views may be needed, these additional views do not necessarily constitute a diagnostic mammogram, unless there are specific findings that require investigation.

Medicare Part B covers diagnostic mammography services if they are furnished by a facility that meets the certification requirements of section 354 of the Public Health Service Act (PHS Act), as implemented by 21 CFR part 900, subpart B. As of October 1, 1994, the Mammography Quality Standards Act requires that all mammography centers that bill Medicare be certified by the Food and Drug Administration (FDA). Medicare will only reimburse FDA-certified mammography centers.

A physician (or qualified non-physician practitioner) referral is required for diagnostic mammography. The patient must be under the care of the physician (or qualified non-physician practitioner who orders the procedure. The order should specify the diagnosis prompting the referral for a diagnostic mammogram.

Diagnostic mammography should be performed under the direct, on-site supervision of an interpreting physician qualified in mammography.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION 77051 DETECTION) WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION, WITH OR WITHOUT

DIGITIZATION OF FILM RADIOGRAPHIC IMAGES; DIAGNOSTIC MAMMOGRAPHY (LIST SEPARATELY IN

ADDITION TO CODE FOR PRIMARY PROCEDURE)

77052

COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES; SCREENING MAMMOGRAPHY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

77055 MAMMOGRAPHY; UNILATERAL

77056 MAMMOGRAPHY; BILATERAL

77057 SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF EACH BREAST)

G0202 SCREENING MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, BILATERAL, ALL VIEWS G0204 DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, BILATERAL, ALL VIEWS G0206 DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, UNILATERAL, ALL VIEWS

ICD-9 Codes that Support Medical Necessity

For screening mammography (77057 or G0202):

V76.11 SCREENING MAMMOGRAM FOR HIGH-RISK PATIENT

V76.12 OTHER SCREENING MAMMOGRAM

For screening mammography that turns into diagnostic mammography (77055 GH or 77056 GH): GH modifier: Diagnostic mammography converted from screening mammogram on same day:

V76.12 OTHER SCREENING MAMMOGRAM

For diagnostic mammography (77055, 77056, G0204 or G0206):

174.0 - 174.9 opens in new window

175.0 - 175.9 opens in new window

MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE

MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST - MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST

196.3 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF AXILLA AND UPPER LIMB

198.2 SECONDARY MALIGNANT NEOPLASM OF SKIN

198.81 SECONDARY MALIGNANT NEOPLASM OF BREAST

217 BENIGN NEOPLASM OF BREAST

232.5 CARCINOMA IN SITU OF SKIN OF TRUNK EXCEPT SCROTUM

233.0 CARCINOMA IN SITU OF BREAST

238.3 NEOPLASM OF UNCERTAIN BEHAVIOR OF BREAST

239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN

239.3 NEOPLASM OF UNSPECIFIED NATURE OF BREAST

451.89 PHLEBITIS AND THROMBOPHLEBITIS OF OTHER SITES

610.0 - 610.9 opens in

new window SOLITARY CYST OF BREAST - BENIGN MAMMARY DYSPLASIA UNSPECIFIED

611.1 INFLAMMATORY DISEASE OF BREAST

611.2 HYPERTROPHY OF BREAST

611.3 FISSURE OF NIPPLE

611.4 FAT NECROSIS OF BREAST

611.5 ATROPHY OF BREAST

611.6 GALACTOCELE

611.7 GALACTORRHEA NOT ASSOCIATED WITH CHILDBIRTH

611.71 MASTODYNIA

611.72 LUMP OR MASS IN BREAST

611.79 OTHER SIGNS AND SYMPTOMS IN BREAST

611.81 PTOSIS OF BREAST

611.82 HYPOPLASIA OF BREAST

611.83 CAPSULAR CONTRACTURE OF BREAST IMPLANT

611.89 OTHER SPECIFIED DISORDERS OF BREAST

793.80 UNSPECIFIED ABNORMAL MAMMOGRAM

793.81 MAMMOGRAPHIC MICROCALCIFICATION

793.82 INCONCLUSIVE MAMMOGRAM

793.89 OTHER (ABNORMAL) FINDINGS ON RADIOLOGICAL EXAMINATION OF BREAST V10.3 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST

Diagnoses that Support Medical Necessity

N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

. Documentation supporting the medical necessity, of a diagnostic mammogram, such as ICD-9-CM diagnosis codes, progress notes, etc., must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.

. A clear, clinical indication for the diagnostic mammogram/breast Sonography must be documented in the medical record as well as in the referral order.

• When a diagnostic mammogram is ordered, the medical records must clearly support that the patient is under the care of the referring physician or qualified non-physician practitioner.

. The medical record must include a formal written report describing all the views completed.

. A physician's order for the diagnostic mammography/breast Sonography must be on file in the medical record. The physician's order must include the clinical reason for the referral.

. If the examination began as a screening mammogram and additional films were ordered based on abnormal results, the specific abnormality must be documented in the record and the -GH modifier must be documented on the claim line with the CPT procedure code for a diagnostic mammogram.

. Documentation must be made available to Medicare upon request.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to medical review.

Sources of Information and Basis for Decision

National Guideline Clearinghouse (2008) Screening mammography for women 40 to 49 years of age: a clinical practice guideline from the American College of Physicians. Retrieved from www.guidelines.gov/summary on November 17, 2008.

National Guideline Clearinghouse (2008) Diagnosis of breast disease. Retrieved from www.guidelines.gov/summary on November 17, 2008

National Comprehensive Cancer Network (2008) NCCN Clinical Practice Guidelines in OncologyTM Breast cancer screening and diagnosis guidelines. V.1.2008 retrieved from www.nccn.org on November 17, 2008

National Comprehensive Cancer Network (2008) NCCN Clinical Practice Guidelines in OncologyTM Breast Cancer Risk Reduction v.1.2008 Retrieved from www.nccn.org on November 17, 2008

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from all related specialties.

Florida Contractor Advisory Committee Meeting held on March 7, 2009.

Puerto Rico/U.S. Virgin Islands Contractor Advisory Meeting held on March 19, 2009

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period

Revision History Number 3

Revision History Explanation Revision Number:3 Start Date of Comment Period:N/A

Start Date of Notice Period:N/A Revised Effective Date:11/04/2010

LCR B2010-075

Explanation of Revision: Added new language to Documentation Requirement Section – “of a diagnostic mammogram” added. The effective date of this revision is based on date of service.

Revision Number:2

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2009 Revised Effective Date: 10/01/2009

LCR B2009-098

September 2009 Update

Explanation of Revision: Annual 2010 ICD-9-CM Update. Added diagnosis code 793.82 for procedure codes 77055, 77056, G0204, or G0206. Descriptor revised for diagnosis code 793.89 for procedure codes 77055, 77056, G0204, and G0206. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:02/20/2009 Start Date of Notice Period:05/01/2009 Revised Effective Date: 06/30/2009

LCR B2009-069

April 2009 Update

Explanation of Revision: LCD revised to clarify indications and limitations for screening and diagnostic mammography. New technology codes added to the “CPT/HCPCS Codes” section of the LCD and CPT code 76645 was deleted from the “CPT/HCPCS Codes” section of the LCD. Revised “Documentation Requirements” section regarding documentation of ordering/referring physician of diagnostic mammograms. Title of LCD changed to reflect coverage for screening and diagnostic mammography procedures. “Contractor’s Determination Number” 77055 was added to the LCD. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) there was no previous LCD on this subject. This document (L29328) is effective on 02/02/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

77055 descriptor was changed in Group 1 77056 descriptor was changed in Group 1 77057 descriptor was changed in Group 1

Reason for Change