Contractor Name
HealthNow

Contractor Number
00801

Contractor Type
Carrier

LCD Database ID Number
L3761

LCD Title
Breast Imaging: Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

Contractor's Determination Number
RD001E08

AMA CPT / ADA CDT Copyright Statement
CPT codes, descriptions, and other data only are copyright 2007 American Medical Association (or such other data of publication of CPT). All Rights Reserved. Applicable FARS/DFARS clauses apply. CDT-4 codes and descriptions are copyright 2002, 2004 American Dental Association. All rights reserved.

CMS National Coverage Policy

   -   Title XVIII of the Social Security Act, section 1862(a)(7)

       This section excludes routine physical checkups.

   -   Title XVIII of the Social Security Act, section 1862(a)(1)(A)

       This section allows coverage and payment for only those services that
       are considered to be reasonable and necessary.

   -   Title XVIII of the Social Security Act, section 1862(a)(1)(F)

       This section excludes payment for screening mammography which is
       performed more frequently than is covered.

   -   Title XVIII of the Social Security Act, Section 1833(e)

       This section prohibits Medicare payment for any claim that lacks the
       necessary information to process the claim.

   -   Code of Federal Regulations (CFR), Title 21, part 900.11, subpart B

       This section specifies FDA certification requirements for suppliers of
       mammography services.

   -   Code of Federal Regulations (CFR), Title 42, part 410.34, subpart B

       This section specified condition for and limitation on coverage.

   -   Balanced Budget Act of 1997, Section 4101

       This section provides coverage for annual screening mammograms for all
       women age 40 and over and waives the Part B deductible for screening
       mammography.

   -   CMS Manual System, Pub 100-4, Medicare Claims Processing, Chapter 18,
       section 20

       This section outlines coverage of screening mammography and special
       billing instructions when radiologist interpretation results in
       additional films.

   -   CMS Manual System, Pub 100-3, Medicare National Coverage
       Determinations Manual, Chapter 1, Section 220.5

       This section outlines coverage of ultrasound diagnostic procedures.

   -   CMS Manual System, Pub 100-4, Medicare Claims Processing, Chapter 13,
       Section 90

       This section outlines coverage of transportation costs in connection
       with the furnishing of diagnostic tests.

   -   Code of Federal Regulations (CFR), Title 42 CFR 410.32, subpart B

       This section of the Code of Federal Regulations contains the
       requirement for diagnostic testing.

Oversight Region
Region II

CMS Consortium
Northeast

Original Determination Effective Date
02/01/2000

Revision Effective Date
01/01/2007

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity
This policy describes mammography, magnetic resonance imaging of the breast, ultrasonic evaluation of the breast, and ductography.

Screening mammography is a radiological procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer and includes a physician's interpretation of the results. It is inherently bilateral. The minimum requirements of a screening mammogram are cranio-caudal (CC) and medio-lateral oblique (MLO) views.

A diagnostic mammography subsequent to a suspicious screening mammography may include extra views without repeating the cranio-caudal (CC) and medio-lateral oblique (MLO) views, when the two tests are performed within a reasonable proximity of time of each other.

Diagnostic mammography is the specific evaluation of a patient with signs or symptoms of a breast disorder, or with screening-detected abnormalities. The goal of this radiographic evaluation is to arrive at precise management decisions, such as sonography, magnetic resonance imaging (MRI), biopsy, etc. Diagnostic mammography is to be distinguished from screening mammography in that the latter is done on patients who are asymptomatic. The minimum requirements for a diagnostic mammogram are cranio-caudal (CC) and medio-lateral oblique (MLO) views. Additional views may be required, but are considered part of the complete diagnostic examination.

The components of a screening mammogram include the radiographic test (the mammogram itself), interpretation and report, and the communication of the results to the patient.

The components of a diagnostic mammogram include a brief history (reason for the exam), palpation of the breasts (when indicated), the radiographic test (the mammogram itself), interpretation and report, and the communication of the results to the patient.

Breast sonography is the ultrasonic evaluation of an abnormal breast lesion.

Breast MRI is the application of magnetic resonance principles to breast imaging.

Ductography (galactography) is a contrast-enhanced visualization of the breast ducts.

Indications
Screening Mammography
Medicare covers annual screening mammography for all women age 40 and over, and one baseline screening mammography for women between the ages of 35-39. As of this date, screening mammography is no longer subject to the Part B deductible, however, coinsurance does apply. Diagnostic mammograms are still subject to the deductible.

Medicare Part B covers screening mammography services if they are furnished by a supplier that meets the certification requirements of section 354 of the PHS Act, as implemented by Code of Federal Regulations (CFR), title 21, Part 900.11, subpart B. As of October 1, 1994, the Mammography Quality Standards Act requires that all mammography centers that bill Medicare be certified by the Food and Drug Administration (FDA). Medicare will only reimburse FDA-certified mammography centers.

CAD code 76083 (effective through 12/31/2006) OR CAD code 77052 (effective on or after 01/01/2007) billed in conjunction with screening film or digital mammography codes do not require FDA certification.

A physician's referral is not required for a screening mammography.

When a screening mammography detects a radiographic abnormality, prompting the interpreting radiologist to order additional views on the same day, the mammography is no longer considered to be a screening exam and should be reported as a diagnostic mammogram (see "Coding Guideline Document"for instructions on the appropriate billing of these services). Radiologists who order additional views (diagnostic mammogram) may do so without an additional order from the treating physician, but must refer to the treating physician or qualified non-physician practitioner for his/her UPIN and report the condition of the patient back to the treating physician. If there is no treating/referring physician, the radiologist must report the exam results directly to the patient. The cost for additional views is included in the cost of the diagnostic mammography service.

Radiologists who order additional views (diagnostic mammogram) may do so without an additional order from the treating physician and may bill for both the screening mammography and the diagnostic mammography (see "Coding Guideline Document" for instructions on the appropriate billing of these services). The treating physician's UPIN must be entered on the claim for the diagnostic mammography. The results must be communicated to the treating physician as with screening mammography.

The following limitations apply:

   1.  The service must be, at a minimum, a two-view exposure (cranio-caudal
       and a medial-lateral oblique view) of each breast.

   2.  Payment may not be made for screening mammography performed on a woman
       under age 35.

   3.  Payment may only be made for a screening mammography when performed
       after at least 11 months have passed following the month in which the
       last screening mammography service was rendered.

   4.  Mammography facilities that perform screening mammography services may
       not release screening mammography x-rays for interpretation to
       physicians who are not approved under the facilities 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.

   5.  Only one type of screening mammography will be allowed in a calendar
       year. Either a screening mammography ­film CPT code 76092 (effective
       through 12/31/2006) and CPT codes 77057 (effective 01/01/2007) OR a
       screening mammography ­ digital (HCPCS codes G0202) will be paid.

   6.  A screening mammography is not payable for a male beneficiary.

   1.  There are signs or symptoms suggestive of malignancy (e.g., mass, some
       types of spontaneous nipple discharge, skin changes, unilateral breast
       pain, or unilateral axillary lymph nodes);

   2.  There are radiographic abnormalities detected on screening
       mammography;

   3.  There is short interval follow-up (at six month intervals, for 2
       years) necessary for unresolved clinical/radiographic concerns; or

   4.  Diagnostic breast evaluation may be indicated in cases of a personal
       history of malignancy and in cases of benign biopsy-proven breast
       disease. Once clinical stability has been established, the routine use
       of diagnostic mammography over screening mammography is not warranted.

   5.  Performed in a patient with metastatic disease of undetermined
       etiology, in whom the source is suspected to be breast

   6.  Performed in a patient with axillary lymphadenopathy of undetermined
       etiology.

Medicare Part B covers diagnostic mammography services if they are furnished by a facility that meets the certification requirements of section 354 of the PHS Act, as implemented by Code of Federal Regulations (CFR), Title 21, part 900.11, subpart B 21 CFR part 900, subpart B. As of October 1, 1994, the Mammography Quality Standards Act requires that all mammography centers that bill Medicare be certified by the Food and Drug Administration (FDA). Medicare will only reimburse FDA-certified mammography centers.

CAD code 76082 (effective through 12/31/2006) OR CAD code 77051 (effective on or after 01/01/2007) billed in conjunction with diagnostic film or digital mammography codes do not require FDA certification.

A treating provider's (physician or qualified non-physician practitioner) referral is required for a diagnostic mammography (except when performed at the discretion of the radiologist when prompted to do so by findings on the screening mammography). The referral should specify the diagnosis prompting the request for a diagnostic mammogram. When a screening mammogram is converted to a diagnostic mammogram, a note in the radiologist's report will fulfill this provision.//

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

Only one type of diagnostic mammography will be allowed on the same claim. Either a diagnostic mammography ­film [CPT code 76090 or 76091 (effective through 12/31/2006) and CPT codes 77055 or 77056 (effective on or after 01/01/2007)] OR diagnostic mammography ­ digital (HCPCS codes G0204 or G0206) will be paid.

Breast Sonography
Breast sonography may be indicated for conditions such as:

   1.  Guidance for breast interventional procedures

   2.  Assessment of implant related problems

   3.  Radiation treatment planning

   4.  Initial evaluation of palpable masses in women under 30.

   5.  In lactating and pregnant women

   6.  Assessment of palpable abnormalities on physical exam

   7.  Assessment to distinguish simple mastitis from abscess formation

   8.  Assessment of any mass to determine whether it is suitable for
       percutaneous intervention (core biopsy, for instance).

   9.  Assess whether a sonographically visible, but mammographically
       invisible mass may be present with calcification or other suspicious
       finding on mammography, so that ultrasound and/or symptoms when
       mammography has not resolved the issue, as when mammographically dense
       tissue obscures a region of concern.

Breast ultrasonography may be performed, in some cases, without having a diagnostic mammography first. However, an order from the treating physician for the ultrasonography is required. For example: a 22-year-old female presents with a painful breast lump. An ultrasound is performed and documents a large simple cyst, which subsequently is aspirated and resolved without the need for a diagnostic mammography first.

A treating provider's (physician or qualified non-physician practitioner) order is required for breast ultrasound.

Breast sonography should be performed under the general supervision of a physician qualified in breast ultrasonography.

Breast MRI
Breast MRI studies are to be used very selectively. The modality should be restricted to:

   1.  Cases where diagnosis is inconclusive, even after standard work-up;

   2.  Evaluation of the post-operative patient when scar tissue cannot be
       differentiated from tumors;

   3.  Patients with positive axillary nodes but no known primary;

   4.  Patients with rupture of a breast implant; or

   5.  Determination of the extent of disease in patients with known
       malignancy, prior to treatment (to assure confinement to one segment
       of the breast).

A treating provider's (physician or qualified non-physician practitioner) order is required for breast MRI.

Ductogram (Galactogram)
Ductography is useful as an aid in diagnosing the cause of an abnormal nipple discharge and is valuable in diagnosing intraductal papillomas.

Ductography should be performed under the personal supervision of a physician qualified in ductography.

A treating provider's (physician or qualified non-physician practitioner) referral is required for ductography.

General Limitations
A diagnostic mammogram, a breast sonogram, or a breast MRI for a diagnosis of neoplasm of unspecified nature of bone, soft tissue and skin (239.2) is acceptable only when related to the breast (i.e., metastasis).

An evaluation and management (E&M) service (e.g., 99201-99275) should not be coded in addition to the mammogram on the same date or on a subsequent date, by a provider whose sole responsibility is the performance of the mammogram (e.g., a radiologist).

A physician such as an obstetrician, gynecologist, or breast surgeon may perform an E&M service in addition to the mammogram if there are separately identifiable services rendered other than the components of the mammogram.

The interpretation of a mammogram [76090-76092 (effective through 12/31/2006), 77055-77057 (effective on or after 01/01/2007), G0202, G0204, G0206 with the 26 modifier] may not be billed by a provider reviewing the test as part of another service (e.g., E&M service) if the interpretation has already been billed by the mammographer.

Transportation costs are associated with mobile units for diagnostic mammography tests only. There is no separate transportation cost allowed for screening mammography, or other breast imaging procedures. To receive transportation payments, the approved portable x-ray supplier must also meet the certification requirements of section 354 of the Public Health Service Act.

Coverage Topic
Diagnostic Tests and X-Rays

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

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

    99999           Not Applicable

CPT/HCPCS Codes
CPT codes 76082, 76083, 76086, 76088, 76090, 76091, 76092, 76093 and 76094 were effective for dates of service through 12/31/2006.

    19030           INJECTION PROCEDURE ONLY FOR MAMMARY DUCTOGRAM OR
                    GALACTOGRAM

    76645           ULTRASOUND, BREAST(S) (UNILATERAL OR BILATERAL),
                    REAL TIME WITH IMAGE DOCUMENTATION

    77051           COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM
                    ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION)
                    WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION,
                    WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC
                    IMAGES; DIAGNOSTIC MAMMOGRAPHY (LIST SEPARATELY IN
                    ADDITION TO CODE FOR PRIMARY PROCEDURE)

    77052           COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM
                    ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION)
                    WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION,
                    WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC
                    IMAGES; SCREENING MAMMOGRAPHY (LIST SEPARATELY IN
                    ADDITION TO CODE FOR PRIMARY PROCEDURE)

    77053           MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT,
                    RADIOLOGICAL SUPERVISION AND INTERPRETATION

    77054           MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS,
                    RADIOLOGICAL SUPERVISION AND INTERPRETATION

    77055           MAMMOGRAPHY; UNILATERAL

    77056           MAMMOGRAPHY; BILATERAL

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

    77058           MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR
                    WITH CONTRAST MATERIAL(S); UNILATERAL

    77059           MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR
                    WITH CONTRAST MATERIAL(S); BILATERAL

    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

Does the CPT 30% Coding Rule Apply?
No

ICD-9 Codes that Support Medical Necessity
TRUNCATED DIAGNOSIS CODES ARE NOT ACCEPTABLE.

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider's responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the service was performed.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid. Further, these ICD-9-CM codes can be used only with the conditions listed in the "Indications" and "Limitations" section of this LCD.

For screening mammography codes 76083, 76092, G0202 (effective through 12/31/2006) OR 77052, 77057 and G0202 (effective on or after 01/01/2007):

    V76.11          Screening mammogram for high-risk patients

    V76.12          Other screening mammogram

For diagnostic mammography and screening mammography that converts to diagnostic mammography [Codes 76082, 76090, 76091, G0204, and G0206 (effective through 12/31/2006) OR 77051, 77055, 77056, G0204 and G0206 (effective on or after 01/01/2007)]:

    174.0-174.9     Malignant neoplasm of female breast

    175.0-175.9     Malignant neoplasm of male breast

    198.2           Secondary malignant neoplasm of skin of the breast

    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 Other and
                    unspecified sites and tissues; breast

    239.2           Neoplasm of unspecified nature of bone soft tissue
                    and skin

    239.3           Neoplasm of unspecified nature of breast

    451.89          Thrombophlebitis of breast

    610.0           Solitary cyst of breast

    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 (nipple
                    discharge)

    611.8*          Other specified disorders of breast

    785.6           Enlargement of lymph nodes

    793.80          Nonspecific abnormal finding on radiological and
                    other examination of body structure, abnormal
                    mammogram, breast; abnormal mammogram unspecified

    793.81          ; breast, mammographic microcalcification

    793.89          ; breast, other abnormal findings on radiological
                    examination of breast

    922.0           Contusion of breast

    V10.3           Personal history of malignant neoplasm of breast

    V10.89**        Personal history of malignant neoplasms of other
                    sites, other

    V45.83**        Breast implant removal status

    V67.1           Following radiotherapy

    V67.2           Following chemotherapy

   *   Use ICD-9-CM code 611.8 for hematoma

   **  ICD-9-CM codes V10.89 and V45.83 may be reported only until clinical
       stability has been established.

    174.0-174.9     Malignant neoplasm of female breast

    175.0-175.9     Malignant neoplasm of male breast

    198.2           Secondary malignant neoplasm of skin of the breast

    198.81          Secondary malignant neoplasm of breast

    217             Benign neoplasm of breast

    233.0           Carcinoma in situ of breast

    238.3           Neoplasm of uncertain behavior of other and
                    unspecified sites and tissues; breast

    239.2           Neoplasm of unspecified nature of bone, soft tissue
                    and skin

    239.3           ; breast

    610.0           Benign mammary dysplasia, 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 dysplasia

    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

    611.72          Lump or mass in breast

    611.79          Other signs and symptoms in breast

    611.8***        Other specified disorders of breast

    611.9***        Unspecified breast disorder

    793.80          Nonspecific abnormal finding on radiological and
                    other examination of body structure, abnormal
                    mammogram, breast; abnormal mammogram unspecified

    793.81          ; breast, mammographic microcalcification

    793.89          ; breast, other abnormal findings on radiological
                    examination of breast

    996.54          Mechanical complication of breast prosthesis

   *** ICD-9-CM codes 610.1-610.4, 610.8-610.9, 611.2-611.6, 611.8-611.9
       should be reported only after mammography and focal findings.

    611.79          Other signs and symptoms in breast (nipple
                    discharge)

ICD-9-CM Codes That DO NOT Support Medical Necessity:
Use of any ICD-9-CM code not listed in the "ICD-9-CM Codes That Support Medical Necessity" section of this LCD will be denied.

Documentation Requirements

   1.  Documentation must support the ICD-9-CM code submited with each claim.
       If the ICD-9-CM code is not documented, the claim may be denied.

   2.  A clear, clinical indication for the diagnostic mammogram/breast
       sonogram 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.

   3.  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.

   4.   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 (prior to
       01/01/2002) or GG modifier (on or after 01/01/2002) must be documented
       on the claim line with the CPT procedure code for a diagnostic
       mammogram.

   5.  Documentation must be available to Medicare upon request.

Utilization Guidelines
Refer to the Indications section of this LCD.

Sources of Information and Basis for Decision

   1.  Cancer Medicine, Third Edition, editors Holland, Frei, Best and
       Morton, Lea and Febiger Publishing, 1993.

   2.  Standards, American College of Radiology, Reston, VA, 1997.

   3.  National Guideline Clearinghouse. "Recommended Breast Cancer
       Surveillance Guidelines." 1999.

   4.  Screening vs. Diagnostic Mammography." CPT Assistant, Volume 6, Issue
       7, July 1996.

   5.  Adams, Song, and Kantorovich, "Breast Symptoms Among Women Enrolled in
       a Health Maintenance Organization," Annals of Internal Medicine, Vol.
       130, No. 8, April 1999.

   6.  "Ductogram (Galactogram): Imaging the Breast Ducts," Breast Health,
       Imaginiscorp.com, August 5, 1999.

   7.  "What is Breast MRI?" Department of Radiology, Magnetic Resonance
       Science Center at UC San Francisco.

   8.  "Expanded Role of Ultrasound in Breast Masses," Radiology, Vol. 196,
       1995.

   9.  "High Definition Imaging: The Role of Ultrasound in the Diagnosis of
       Breast Cancer (Summary of an International Multicenter Clinical
       Study)," ATL Ultrasound Reference Library.

   10.  Carrier Medical Directors (Group Health Incorporated, Empire Medicare
       Services and Upstate Medicare Division).

   11. New York State Radiological Society Carrier Advisory Committee
       representative.

   -   This policy was presented at the June 9, 1999 Carrier Advisory
       Committee.

   -   This policy was revised and brought back to the Carrier Advisory
       Committee to address new Center for Medicare and Medicaid Services
       (CMS) regulations regarding a screening mammogram that turns into a
       diagnostic mammogram and to require more specific record
       documentation; correct billing procedures for diagnostic mammograms
       and Evaluation and Management services on the same day; and to address
       the 1999 focused medical review (FMR) aberrancies of CPT procedure
       codes 76090, 76091, and 76645. Screening and diagnostic mammography,
       breast MRI, breast sonography, and ductography services were all
       combined into one comprehensive policy.

   -   This policy does not reflect the sole opinion of the contractor or
       contractor medical director. Although the final decision rests with
       the contractor, this policy was developed in cooperation with advisory
       groups, which includes representatives from the New York State
       Radiological Society, the New York State Society of Surgeons, the New
       York State Chapter of the American Society of Internal
       Medicine-American College of Physicians, the American College of
       Obstetricians and Gynecologists, the New York State Society of
       Hematology and Oncology, and the Medical Society of the State of New
       York.

End Date of Comment Period
07/24/1999

Start Date of Notice Period
11/19/2007

Revision History Number
8

Revision History Explanation
Revision #8: Removed ICD-9CM code V76.12 from list of covered ICD-9CM codes for the "diagnostic mammography and screening mammography that converts to diagnostic mammography." This ICD-9CM code is only appropriate for use with a screening mammography. When additional views are required after a screening mammography is performed and a diagnositic mammography is also billed, the diagnostic mammography would be billed using the appropriate ICD-9CM code listed under the diagnostic mammography, along with the modifier GG, and the screening mammography would be billed using ICD-9CM code V76.12 (or V76.11), refer to Coding Guidelines. This LCD was also revised in accordance with CR 5327 and 5306 updating the CPT code section with new CPT/HCPCS effective on or after 01/01/2007.

Revision #7: CMS Transmittal 426 has been rescinded and replaced with Transmittal 705, dated October 7, 2005. It changes the effective date for the addition of V76.11 from July 1, 2005 to January 1, 1998.

Revision #6:

   1.  Revision 6, effective 07/01/2005, expands the LCD to add ICD-9CM codes
       V76.11 as an acceptable ICD-9CM code for screening mammography, as per
       CMS Transmittal 426, CR 3562.

   2.  Outdated information was removed.

Revision #5: Revision 5 expanded the policy based on comments from the Radiology Society (NJ):

   -   Added several indications in the Indication and Limitations section of
       the policy.

   -   Added ICD-9-CM codes 610.0, 611.8, 785.6, 922.0, V10.89, V45.83, V67.1
       and V67.2 to the list of payable ICD-9-CM codes for diagnostic
       mammography and a screening mammography that converts to a diagnostic
       mammography.

   -   Added ICD-9-CM codes 610.1-610.9, 611.2-611.6, 611.8-611.9 to the list
       of payable ICD-9-CM codes for breast echography/sonography and breast
       MRI

Correction: Under "Reasons for Denial" #20, third bullet, correct the date of service to read:

"For dates of service on or after January 1, 2004, 76082 must be billed with the primary codes 76090, 76091, G0204, or G0206."

Revision #4: Effective 01/01/2004, revision 4 resulted in the following changes: (most changes were based on Transmittal 1814, CR 2632).

   1.  CPT codes 76082 and 76083 are added effective 01/01/2004 to describe
       procedures done using CAD equipment.

   2.  CPT codes 76085 and HCPCS code G0236 are deleted as of 12/31/2003.

   3.  A statement is added to clarify that the CAD codes are not subject to
       FDA certification.

   4.  Claims for screening mammography received without an ICD-9CM code will
       be returned as unprocessable. ICD-9CM code V76.12 will no longer be
       plugged in by the carrier.

   5.  ICD-9CM codes 611.79 and 996.54 are added to the ICD-9CM codes that
       support medical necessity for Breast Echography/Sonography and Breast
       MRI.

Revision #3: Effective 04/01/2003, the following changes and clarifications were included in this revision:

   1.  The narrative descriptions for HCPCS codes G0202, G0204 and G0206 have
       been changed.

   2.  Primary codes to be reported with CPT 76085 have been updated.

   3.  Primary codes to be reported with HCPCS code G0236 have been updated.

   4.  Only one type of screening mammography (film or digital) may be
       allowed.

   5.  Only one type of diagnostic mammography (film or digital) may be
       allowed

Revision #2: This policy was revised on 04/16/2002 to make the following changes based on section 104 of the Benefits Improvement and Protection Act (BIPA) of 2000 and CMS Change Request #1520 and #1837, as well as the annual HCPCS 2002 updates.

   1.  New HCPCS codes were added.

   2.  Verbiage was added specifying that a diagnostic mammography and
       screening mammography may both be paid when performed on the same day
       under certain conditions.

   3.  Modifier GG was added and must be reported on the diagnostic code to
       show that the test changes from a screening test to a diagnostic test
       on the same day for the same beneficiary.

   4.  Two new add-on codes were added (76085 and G0236).

   5.  Codes G0203, G0205, and G0207, which were added for dates of service
       on or after 04/01/2001 are terminated as of 12/31/2001.

   6.  Verbiage specifying that radiologists who order additional views
       (diagnostic mammogram) may do so without an additional order from the
       treating physician.

   7.  In addition, several ICD-9-CM codes were added to the list of ICD-9-CM
       codes that support medical necessity and truncated ICD-9-CM code 793.8
       was replaced with 793.80, 793.81, and 793.89 for 2002.

   8.  Also added 238.3 and 239.3 for diagnostic and screening mammography
       and breast chography/sonography/breast MRI; as well as V76.12 for
       diagnostic/screening mammography.

Revision #1: This policy, #RD001E01, was revised on 12/12/2000 to add ICD-9-CM codes 793.8 for CPT 76090, 76091, and 610.0 for CPT 76645, to the list of "ICD-9-CM Codes That Support Medical Necessity" to be effective retroactive to the original effective date of the policy. A comment was also added to the "Description" section of the policy to broaden the definition of diagnostic mammograms so that palpation of the breast is included "when indicated."

This LCD was converted from an LMRP on 4/7/2004

Does this LCD contain a "Least Costly Alternative" provision?
No