Local Coverage Article Billing and Coding

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

A56448

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Article Information

General Information

Article ID
A56448
Article Title
Billing and Coding: Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography
Article Type
Billing and Coding
Original Effective Date
01/01/2019
Revision Effective Date
12/01/2022
Revision Ending Date
N/A
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

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

42 CFR Section 410.34 specifies the conditions for and limitation on coverage.

CMS Publication 100-03, Medicare National Coverage Decisions Manual, Chapter 1:

    220.4 Mammograms

MS Publication 100-04, Medicare Claims Processing Manual, Chapter 18:

    20 Mammography Services (Screening and Diagnostic)

 

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L33950 Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography.

 

General Guidelines for Claims submitted to Part A or Part B MAC:

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 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.

 

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

 

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

 

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

A clear, clinical indication for the diagnostic mammogram/breast sonogram/breast MRI/ductogram must be documented in the medical record, as well as in the referral order. A written referral is required for a diagnostic mammogram except when the diagnostic mammogram was initially performed as a screening.

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.

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. The GG modifier must be documented on the claim line with the CPT procedure code for a diagnostic mammogram.

Documentation must be available to Medicare upon request.


Refer to the Indications and Limitations section of the LCD. 

Other Comments:

For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Services to process their claims.

Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC .

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. 

Coding Information

CPT/HCPCS Codes

Group 1

(18 Codes)
Group 1 Paragraph

77046, 77048 (effective 01/01/2019)77058 (end dated 12/31/2018) (not to be used by OPPS providers)
77047, 77049 (effective 01/01/2019)77059 (end dated 12/31/2018) (not to be used by OPPS providers)

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

Group 1 Codes
CodeDescription
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
77063 SCREENING DIGITAL BREAST TOMOSYNTHESIS, BILATERAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
77065 DIAGNOSTIC MAMMOGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PERFORMED; UNILATERAL
77066 DIAGNOSTIC MAMMOGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PERFORMED; BILATERAL
77067 SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW STUDY OF EACH BREAST), INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PERFORMED
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
G0279 DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS, UNILATERAL OR BILATERAL (LIST SEPARATELY IN ADDITION TO 77065 OR 77066)

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. 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 this determination.

For screening mammography code 77067, 77063

Group 1 Codes
CodeDescription
Z12.31 Encounter for screening mammogram for malignant neoplasm of breast

Group 2

(147 Codes)
Group 2 Paragraph

77065, 77066 For diagnostic mammography and screening mammography that converts to diagnostic mammography (codes 77065, 77066, or G0279)

Use ICD-10-CM code N64.89 for hematoma

ICD-10-CM codes Z85.831, Z85.89, or Z98.86 may be reported only until clinical stability has been established.

Group 2 Codes
CodeDescription
C45.9 Mesothelioma, unspecified
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
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C77.3 Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.1 Secondary malignant neoplasm of mediastinum
C78.2 Secondary malignant neoplasm of pleura
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C79.2 Secondary malignant neoplasm of skin
C79.31 Secondary malignant neoplasm of brain
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
C79.81 Secondary malignant neoplasm of breast
C80.0 Disseminated malignant neoplasm, unspecified
C80.1 Malignant (primary) neoplasm, unspecified
D04.5 Carcinoma in situ of skin of trunk
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
D48.5 Neoplasm of uncertain behavior of skin
D48.61 Neoplasm of uncertain behavior of right breast
D48.62 Neoplasm of uncertain behavior of left breast
I80.8 Phlebitis and thrombophlebitis of other sites
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
N61.21 Granulomatous mastitis, right breast
N61.22 Granulomatous mastitis, left breast
N61.23 Granulomatous mastitis, bilateral breast
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 - N64.4 Fissure and fistula of nipple - Mastodynia
N64.51 - N64.53 Induration of breast - Retraction of nipple
N64.59 Other signs and symptoms in breast
N64.89 Other specified disorders of breast
N64.9 Disorder of breast, unspecified
N65.0 Deformity of reconstructed breast
N65.1 Disproportion of reconstructed breast
R59.0 Localized enlarged lymph nodes
R59.1 Generalized enlarged lymph nodes
R59.9 Enlarged lymph nodes, unspecified
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
S20.01XA Contusion of right breast, initial encounter
S20.02XA Contusion of left breast, initial encounter
S21.011A Laceration without foreign body of right breast, initial encounter
S21.012A Laceration without foreign body of left breast, initial encounter
S21.021A Laceration with foreign body of right breast, initial encounter
S21.022A Laceration with foreign body of left breast, initial encounter
S21.031A Puncture wound without foreign body of right breast, initial encounter
S21.032A Puncture wound without foreign body of left breast, initial encounter
S21.041A Puncture wound with foreign body of right breast, initial encounter
S21.042A Puncture wound with foreign body of left breast, initial encounter
S21.051A Open bite of right breast, initial encounter
S21.052A Open bite of left breast, initial encounter
S28.211A Complete traumatic amputation of right breast, initial encounter
S28.212A Complete traumatic amputation of left breast, initial encounter
S28.221A Partial traumatic amputation of right breast, initial encounter
S28.222A Partial traumatic amputation of left breast, initial encounter
T85.41XA Breakdown (mechanical) of breast prosthesis and implant, initial encounter
T85.42XA Displacement of breast prosthesis and implant, initial encounter
T85.43XA Leakage of breast prosthesis and implant, initial encounter
T85.44XA Capsular contracture of breast implant, initial encounter
T85.49XA Other mechanical complication of breast prosthesis and implant, initial encounter
Z03.89 Encounter for observation for other suspected diseases and conditions ruled out
Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z77.118 Contact with and (suspected) exposure to other environmental pollution
Z77.123 Contact with and (suspected) exposure to radon and other naturally occurring radiation
Z77.128 Contact with and (suspected) exposure to other hazards in the physical environment
Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)
Z77.9 Other contact with and (suspected) exposures hazardous to health
Z85.3 Personal history of malignant neoplasm of breast
Z85.831 Personal history of malignant neoplasm of soft tissue
Z85.89 Personal history of malignant neoplasm of other organs and systems
Z92.89 Personal history of other medical treatment
Z98.86 Personal history of breast implant removal

Group 3

(107 Codes)
Group 3 Paragraph

For breast echography/sonography and breast MRI (codes 76645 for DOS 12/31/14 and prior, 76641, 76642, 77046, 77048 (non-OPPS code),77047, 77049(non-OPPS code), C8903, C8905, C8906, and C8908)

ICD-10-CM codes N60.11, N60.12, N60.21, N60.22, N60.31, N60.32, N60.41, N60.42, N60.81, N60.82, N64.0-N64.3, N64.89, or N64.9 should be reported only after mammography and focal findings.

Group 3 Codes
CodeDescription
C45.9 Mesothelioma, unspecified
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
C50.921 Malignant neoplasm of unspecified site of right male breast
C50.922 Malignant neoplasm of unspecified site of left male breast
C77.3 Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes
C79.2 Secondary malignant neoplasm of skin
C79.81 Secondary malignant neoplasm of breast
C80.1 Malignant (primary) neoplasm, unspecified
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
D05.91 Unspecified type of carcinoma in situ of right breast
D05.92 Unspecified 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
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
D49.3 Neoplasm of unspecified behavior of 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 - N64.3 Fissure and fistula of nipple - Galactorrhea not associated with childbirth
N64.4 Mastodynia
N64.51 - N64.53 Induration of breast - Retraction of nipple
N64.59 Other signs and symptoms in breast
N64.89 Other specified disorders of breast
N64.9 Disorder of breast, unspecified
N65.0 Deformity of reconstructed breast
N65.1 Disproportion of reconstructed breast
R92.0 - R92.2 Mammographic microcalcification found on diagnostic imaging of breast - 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
T85.42XA Displacement of breast prosthesis and implant, initial encounter
T85.43XA Leakage of breast prosthesis and implant, initial encounter
T85.44XA Capsular contracture of breast implant, initial encounter
T85.49XA Other mechanical complication of breast prosthesis and implant, initial encounter
Z85.3 Personal history of malignant neoplasm of breast

Group 4

(4 Codes)
Group 4 Paragraph

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

 

Group 4 Codes
CodeDescription
N64.51 Induration of breast
N64.52 Nipple discharge
N64.53 Retraction of nipple
N64.59 Other signs and symptoms in breast

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

N/A

ICD-10-PCS Codes

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.

CodeDescription
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital

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.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.


CodeDescription
0401 Other Imaging Services - Diagnostic Mammography
0402 Other Imaging Services - Ultrasound
0403 Other Imaging Services - Screening Mammography
0409 Other Imaging Services - Other Imaging Services
0510 Clinic - General Classification
0520 Freestanding Clinic - General Classification
0521 Freestanding Clinic - Clinic Visit by Member to RHC/FQHC
0522 Freestanding Clinic - Home Visit by RHC/FQHC Practitioner
0524 Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF or Skilled Swing Bed in a Covered Part A Stay
0525 Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF (not in a Covered Part A Stay) or NF or ICF MR or Other Residential Facility
0527 Freestanding Clinic - Visiting Nurse Service(s) to a Member's Home when in a Home Health Shortage Area
0528 Freestanding Clinic - Visit by RHC/FQHC Practitioner to Other non-RHC/FQHC site (e.g. Scene of Accident)
0614 Magnetic Resonance Technology (MRT) - MRI - Other

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
12/01/2022 R10

R10
Revision Effective: 12/01/2022
Revision Explanation: Annual review, no changes were made.

11/25/2021 R9

R9
Revision Effective: 11/25/2021
Revision Explanation: Annual review, no changes were made.

10/01/2020 R8

R8
Revision Effective: 10/01/2020
Revision Explanation: Added code N61.21, N61.22, and N61.23 as added as coverage to NCD effective 10/01/2020.

01/01/2020 R7

R7
Revision Effective: N/A
Revision Explanation: Annual review, no changes were made.

01/01/2020 R6

R6
Revision Effective: N/A
Revision Explanation: revision #2 froma annual ICD-10 update in 2019 N63.2 should be N63.25. Codes N63.15 and N63.25 were added on 10/01/2019.

01/01/2020 R5

R5
Revision Effective: 01/01/2020
Revision Explanation: The following codes were removed as they are no longer covered under NCD 220.4 based on CR 11392 from group 1: C50.911, C50.912, C50.821, C50.922, D05.91, D05.92, D49.2, D49.3, N60.91, N60.92, S21.001A, and S21.002A and N60.91 and N60.92 were removed from group 2.

11/28/2019 R4

R4

Revision Effective:11/28/2019

Revision Explanation: Added 77063 to the group one  paragraph in the ICD-10 section as it was left off in error.

11/28/2019 R3

R3

Revision Effective:11/28/2019

Revision Explanation: Added other comments section and additional information for documentation in article text.

10/01/2019 R2

R1

Revision Effective:10/01/2019

Revision Explanation: New code N63.15 and N63.2 were added to ICD-10 group 2 and 3 during the annual ICD-10 update.

09/19/2019 R1

R1

Revision Effective: 09/19/2019

Revision Explanation: Converted article into new Billing and Coding template no other changes made.

 

Associated Documents

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Public Versions
Updated On Effective Dates Status
11/23/2022 12/01/2022 - N/A Currently in Effect You are here
11/19/2021 11/25/2021 - 11/30/2022 Superseded View
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