SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

A52849

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Contractor Information

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General Information

Source Article ID
N/A
Article ID
A52849
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
04/01/2021
Revision Ending Date
12/31/2023
Retirement Date
N/A
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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.

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CMS National Coverage Policy

N/A

Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography (L33585). 

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and UPIN or NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

 For claims submitted to the Part B MAC:

All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.

An evaluation and management (E&M) service or consultation by the radiologist on the same day (or subsequent days) as a breast sonogram, MRI, or ductogram or their components should not be separately coded or billed.

For breast sonography, breast MRI, and ductogram, the NPI of the treating/ordering physician or qualified non-physician practitioner is required on the claim. Report this number in item 17a of the CMS-1500 form or in the electronic equivalent.

BREAST SONOGRAPHY

If performed bilaterally, a modifier 50 may be reported with CPT code 76641 or 76642.

BREAST MRI

Only CPT codes 77046, 77047, 77048, 77049 may be reported for any given date of service.

MAMMARY DUCTOGRAM OR GALACTOGRAM

Only CPT code 77053 or 77054 may be reported for any given date of service.

Use CPT code 19030 for the injection of contrast.

For claims submitted to the Part A MAC:

CPT code 19030 is a packaged service and is not separately payable.

BREAST SONOGRAPHY

  • For Part A billing of breast sonography, use the following:
  • CPT codes 76641 and 76642

BREAST MRI

For Part A billing of breast MRI, use the following:

  • HCPCS code C8903, C8905, C8906, C8908
  • CPT codes 77046 and 77047

 DUCTOGRAPHY

For Part A billing of ductography, use the following:

  • CPT codes 77053 or 77054

Documentation Requirements:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

A clear, clinical indication for the breast sonogram/breast MRI/ductogram must be documented in the medical record, as well as in the referral order.

The medical record must include a formal written report describing all the views completed. The formal written report must include the reason for the test, a description of the test, the interpretation and results of the test, and the name of the physician to whom the report is being sent.

Documentation must be available to Medicare upon request.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

(13 Codes)
Group 1 Paragraph

CPT code 77048 and 77049 should not be used by OPPS providers.

HCPCS codes C8903 through C8908 are to be billed to the Part A MAC and not the Part B MAC.

Group 1 Codes
Code Description
19030 INJECTION PROCEDURE ONLY FOR MAMMARY DUCTOGRAM OR GALACTOGRAM
76641 ULTRASOUND, BREAST, UNILATERAL, REAL TIME WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED; COMPLETE
76642 ULTRASOUND, BREAST, UNILATERAL, REAL TIME WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED; LIMITED
77046 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT CONTRAST MATERIAL; UNILATERAL
77047 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT CONTRAST MATERIAL; BILATERAL
77048 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND WITH CONTRAST MATERIAL(S), INCLUDING COMPUTER-AIDED DETECTION (CAD REAL-TIME LESION DETECTION, CHARACTERIZATION AND PHARMACOKINETIC ANALYSIS), WHEN PERFORMED; UNILATERAL
77049 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND WITH CONTRAST MATERIAL(S), INCLUDING COMPUTER-AIDED DETECTION (CAD REAL-TIME LESION DETECTION, CHARACTERIZATION AND PHARMACOKINETIC ANALYSIS), WHEN PERFORMED; BILATERAL
77053 MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, RADIOLOGICAL SUPERVISION AND INTERPRETATION
77054 MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, RADIOLOGICAL SUPERVISION AND INTERPRETATION
C8903 MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; UNILATERAL
C8905 MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, BREAST; UNILATERAL
C8906 MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; BILATERAL
C8908 MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, BREAST; BILATERAL
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(114 Codes)
Group 1 Paragraph

The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the related LCD.

For breast echography/sonography and breast MRI (76641 and 76642), 77046, 77047, 77048, 77049, C8903, C8905, C8906 and C8908)

Group 1 Codes
Code Description
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.221 Malignant neoplasm of upper-inner quadrant of right male breast
C50.222 Malignant neoplasm of upper-inner quadrant of left male breast
C50.311 Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.321 Malignant neoplasm of lower-inner quadrant of right male breast
C50.322 Malignant neoplasm of lower-inner quadrant of left male breast
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.421 Malignant neoplasm of upper-outer quadrant of right male breast
C50.422 Malignant neoplasm of upper-outer quadrant of left male breast
C50.511 Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.521 Malignant neoplasm of lower-outer quadrant of right male breast
C50.522 Malignant neoplasm of lower-outer quadrant of left male breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C79.2 Secondary malignant neoplasm of skin
C79.81 Secondary malignant neoplasm of breast
D05.01 Lobular carcinoma in situ of right breast
D05.02 Lobular carcinoma in situ of left breast
D05.11 Intraductal carcinoma in situ of right breast
D05.12 Intraductal carcinoma in situ of left breast
D05.81 Other specified type of carcinoma in situ of right breast
D05.82 Other specified type of carcinoma in situ of left breast
D24.1 Benign neoplasm of right breast
D24.2 Benign neoplasm of left breast
D48.61 Neoplasm of uncertain behavior of right breast
D48.62 Neoplasm of uncertain behavior of left breast
N60.01 Solitary cyst of right breast
N60.02 Solitary cyst of left breast
N60.11 Diffuse cystic mastopathy of right breast
N60.12 Diffuse cystic mastopathy of left breast
N60.21 Fibroadenosis of right breast
N60.22 Fibroadenosis of left breast
N60.31 Fibrosclerosis of right breast
N60.32 Fibrosclerosis of left breast
N60.41 Mammary duct ectasia of right breast
N60.42 Mammary duct ectasia of left breast
N60.81 Other benign mammary dysplasias of right breast
N60.82 Other benign mammary dysplasias of left breast
N61.0 Mastitis without abscess
N61.1 Abscess of the breast and nipple
N62 Hypertrophy of breast
N63.11 Unspecified lump in the right breast, upper outer quadrant
N63.12 Unspecified lump in the right breast, upper inner quadrant
N63.13 Unspecified lump in the right breast, lower outer quadrant
N63.14 Unspecified lump in the right breast, lower inner quadrant
N63.15 Unspecified lump in the right breast, overlapping quadrants
N63.21 Unspecified lump in the left breast, upper outer quadrant
N63.22 Unspecified lump in the left breast, upper inner quadrant
N63.23 Unspecified lump in the left breast, lower outer quadrant
N63.24 Unspecified lump in the left breast, lower inner quadrant
N63.25 Unspecified lump in the left breast, overlapping quadrants
N63.31 Unspecified lump in axillary tail of the right breast
N63.32 Unspecified lump in axillary tail of the left breast
N63.41 Unspecified lump in right breast, subareolar
N63.42 Unspecified lump in left breast, subareolar
N64.0 Fissure and fistula of nipple
N64.1 Fat necrosis of breast
N64.2 Atrophy of breast
N64.3 Galactorrhea not associated with childbirth
N64.4 Mastodynia
N64.51 Induration of breast
N64.52 Nipple discharge
N64.53 Retraction of nipple
N64.59 Other signs and symptoms in breast
N64.89 Other specified disorders of breast
N65.0 Deformity of reconstructed breast
N65.1 Disproportion of reconstructed breast
R92.0 Mammographic microcalcification found on diagnostic imaging of breast
R92.1 Mammographic calcification found on diagnostic imaging of breast
R92.2 Inconclusive mammogram
R92.8 Other abnormal and inconclusive findings on diagnostic imaging of breast
T85.41XA Breakdown (mechanical) of breast prosthesis and implant, initial encounter
T85.41XD Breakdown (mechanical) of breast prosthesis and implant, subsequent encounter
T85.41XS Breakdown (mechanical) of breast prosthesis and implant, sequela
T85.42XA Displacement of breast prosthesis and implant, initial encounter
T85.42XD Displacement of breast prosthesis and implant, subsequent encounter
T85.42XS Displacement of breast prosthesis and implant, sequela
T85.43XA Leakage of breast prosthesis and implant, initial encounter
T85.43XD Leakage of breast prosthesis and implant, subsequent encounter
T85.43XS Leakage of breast prosthesis and implant, sequela
T85.44XA Capsular contracture of breast implant, initial encounter
T85.44XD Capsular contracture of breast implant, subsequent encounter
T85.44XS Capsular contracture of breast implant, sequela
T85.49XA Other mechanical complication of breast prosthesis and implant, initial encounter
T85.49XD Other mechanical complication of breast prosthesis and implant, subsequent encounter
T85.49XS Other mechanical complication of breast prosthesis and implant, sequela
T85.79XA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter
T85.79XD Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, subsequent encounter
T85.79XS Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, sequela
Z85.3 Personal history of malignant neoplasm of breast
Z86.000 Personal history of in-situ neoplasm of breast
Z86.018 Personal history of other benign neoplasm
Z86.03 Personal history of neoplasm of uncertain behavior
Z87.42 Personal history of other diseases of the female genital tract

Group 2

(4 Codes)
Group 2 Paragraph

For ductography (galactography) (codes 19030, 77053 and 77054):

Group 2 Codes
Code Description
N64.51 Induration of breast
N64.52 Nipple discharge
N64.53 Retraction of nipple
N64.59 Other signs and symptoms in breast
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
N/A

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
04/01/2021 R8

This article has been updated due to a provider request to add the following diagnosis codes to Group 1 in the "ICD-10 codes that support medical necessity" section: Z86.000, Z86.018, Z86.03, and Z87.42.

10/24/2019 R7

This  Article has been converted to the new Billing and Coding Article.

Bill types and Revenue codes have been removed from this article. Guidance on these codes is available in the Bill type and Revenue code sections.

01/01/2019 R6

Due to the annual CPT/HCPCS Code update the following codes have been removed from the "CPT/HCPCS Codes, Group 1 Codes": 77058, 77059, C8904, and C8907. The following new codes have been added: 77046, 77047, 77048, 77049.

10/01/2018 R5

Removed Bill Type Code 066X and added Bill Types Codes 012X, 013X, 022X, 023X, 071X, 073X, 077X, 085X in the "Coding Information" section.

10/01/2017 R4

The LCD was revised on 10/01/2016 to remove Revenue Codes 0401 and 0403 for diagnostic and screening mammography services. Revenue Code 0401 should have been removed from the article as well. 

10/01/2017 R3

Removed the obsolete references to CPT code 76645 in the “Article Text” and “CPT/HCPCS Codes” sections.

 

10/01/2015 R2 Removed place of service coding guidelines.

Based on the National Coverage Determination (NCD) 220.4, all references to a diagnostic mammography were removed from the article.
10/01/2015 R1 Due to the annual HCPCS update for 2015, CPT code 76645 was deleted and removed from the “CPT/HCPCS Codes” section. An explanatory note regarding the code deletion was added to this section. CPT codes 76641 and 76642 were added as replacement codes. HCPCS code G0279 was added to the “CPT/HCPCS Codes” section. The descriptors were changed for HCPCS codes G0204 and G0206.

The following coding guideline was added regarding add-on codes:

  • HCPCS code G0279 must be billed with the primary code of G0204 or G0206.
The following coding guideline was revised:

For dates of service prior to January 1, 2015, use CPT code 76645 when reporting breast sonography, unilateral or bilateral. It would be inappropriate to use a modifier 50 or to increase the units field, as reimbursement for this code is already based on the procedure being performed bilaterally. For dates of service on or after January 1, 2015, the replacement codes are 76641 and 76642. If performed bilaterally, a modifier 50 may be reported with CPT code 76641 or 76642.

HCPCS code G0279 was added to the following coding guideline:

Claims for the global billing of a diagnostic mammography (77051, 77055, 77056, G0204, G0206 and G0279), a breast sonography (76641 and 76642 for dates of service on or after January 1, 2015 and 76645 for dates of service through December 31, 2014), a breast MRI (77058 and 77059) and a ductography (77053 and 77054 ) are payable under Medicare Part B in the following places of service: office (11), mobile unit (15) and independent clinic (49). When a mobile unit (place of service 15) is sent to other sites such as a nursing facility, adult home or physician office, the place of service reported on the claim should be that of the site where the service was performed such as office (11), nursing facility (32), custodial care facility (33).

CPT codes 76641 and 76642 were added to the following coding guidelines:

Claims for the technical component of a diagnostic mammography (77051, 77055, 77056, G0204 and G0206), a breast sonography (codes 76641 and 76642 for dates of service on or after January 1, 2015 and 76645 for dates of service through December 31, 2014), a breast MRI (77058 and 77059 ) and a ductography (77053 and 77054 ) are payable under Medicare Part B in the following places of service: office (11), mobile unit (15), independent clinic (49), federally qualified health center (FQHC) (50) and rural health clinic (RHC) (72). When a mobile unit (place of service 15) is sent to other sites such as a nursing facility, adult home or physician office, the place of service reported on the claim should be that of the site where the service was performed such as office (11), nursing facility (32), custodial care facility (33).

Claims for the professional component (codes 76641-26 and 76642-26 for dates of service on or after January 1, 2015 and 76645-26 for dates of service through December 31, 2014), 77053-26, 77054-26, 77055-26, 77056-26, 77058-26, 77059-26, G0204-26 and G0206-26) are payable under Medicare Part B in the following places of service: office (11), mobile unit (15), inpatient hospital (21), outpatient hospital (22), emergency room (23) and independent clinic (49). When a mobile unit (place of service 15) is sent to other sites such as a skilled nursing facility, adult home or physician office, the place of service reported on the claim should be that of the site where the service was performed such as office (11), skilled nursing facility (31), nursing facility (32), custodial care facility (33).

CPT codes 76641 and 76642 were added to the following coding guideline:

For Part A billing of breast sonography, use the following:
  • Bill types 12x, 13x, 22x, 23x, and 85x
  • Revenue code 402
  • CPT codes 76641 and 76642 for dates of service on or after January 1, 2015 and 76645 for dates of service through December 31, 2014
Based on the National Coverage Determination (NCD), all references to a screening mammography were removed from the article.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 2
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Public Versions
Updated On Effective Dates Status
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