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SUPERSEDED Billing and Coding Article

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

A56448

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
CGS Administrators, LLC	MAC - Part A	15101 - MAC A	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part B	15102 - MAC B	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part A	15201 - MAC A	J - 15	Ohio
CGS Administrators, LLC	MAC - Part B	15202 - MAC B	J - 15	Ohio

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
11/15/2023

Retirement Date
N/A

AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

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.

Response To Comments

Number	Comment	Response
1

Coding Information

Bill Type Codes

Code	Description
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

Code	Description
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

CPT/HCPCS Codes

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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

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
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

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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

Code	Description
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

Code	Description
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

Code	Description
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

Code	Description
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.

Code	Description
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.

Code	Description
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

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

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

Revision History Date	Revision History Number	Revision 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

Related Local Coverage Documents
LCDs
L33950 - Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

Updated On	Effective Dates	Status
11/29/2023	12/07/2023 - N/A	Currently in Effect	View
11/07/2023	11/16/2023 - 12/06/2023	Superseded	View
11/23/2022	12/01/2022 - 11/15/2023	Superseded	You are here
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Billing and Coding: Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

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Note History

Contractor Information

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General Information

CMS National Coverage Policy

Article Guidance

Response To Comments

Coding Information

Bill Type Codes

Revenue Codes

CPT/HCPCS Codes

Group 1

CPT/HCPCS Modifiers

Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 2

Group 3

Group 4

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

Group 1

ICD-10-PCS Codes

Group 1

Additional ICD-10 Information

Bill Type Codes

Revenue Codes

Other Coding Information

Group 1

Coding Table Information

Revision History Information

Associated Documents

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