LCD/NCD Portal

L29328

 

SCREENING AND DIAGNOSTIC MAMMOGRAPHY

 

01/01/2013

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Screening Mammogram

• 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:

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

o 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.

• Diagnostic mammogram(s) are allowed for the following indications:

o The patient is under the care of the referring/ordering physician or qualified non-physician practitioner.

o There are signs and/or symptoms suggestive of malignancy (mass, some types of spontaneous nipple discharge or skin changes).

o There are possible radiographic abnormalities detected on screening mammography.

o There is short interval follow-up (less than one year) necessary for unresolved clinical/radiographic concerns.

o 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.

o These diagnoses should not, however, routinely warrant a diagnostic mammography.

• A breast implant does not necessarily imply that a mammogram is diagnostic in nature.

o 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.

o 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).

o Medicare will only reimburse FDA-certified mammography centers.

• A physician (or qualified non-physician practitioner) referral is required for diagnostic mammography.

o The patient must be under the care of the physician (or qualified non-physician practitioner) who orders the procedure.

o 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.

 

 

CPT/HCPCS Codes

 

 

77051 COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER 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 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 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST

174.1 MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST

174.2 MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST

174.3 MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST

174.4 MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST

174.5 MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST

174.6 MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST

174.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST

174.9 MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE

175.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST

175.9 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 SOLITARY CYST OF BREAST

610.1 DIFFUSE CYSTIC MASTOPATHY

610.2 FIBROADENOSIS OF BREAST

610.3 FIBROSCLEROSIS OF BREAST

610.4 MAMMARY DUCT ECTASIA

610.8 OTHER SPECIFIED BENIGN MAMMARY DYSPLASIAS

610.9 BENIGN MAMMARY DYSPLASIA UNSPECIFIED

611.0 INFLAMMATORY DISEASE OF BREAST

611.1 HYPERTROPHY OF BREAST

611.2 FISSURE OF NIPPLE

611.3 FAT NECROSIS OF BREAST

611.4 ATROPHY OF BREAST

611.5 GALACTOCELE

611.6 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

 

 

Documentation 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.

 

Treatment Logic

 

• 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.

 

Sources of Information and Basis for Decision

 

FCSO LCD 29328, Screening and Diagnostic Mammography, 01/01/2013. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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

01/01/2013

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

CMS LCD SCREENING AND DIAGNOSTIC MAMMOGRAPHY