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HealthNow UMD
Article -- Coding Guidelines
Contractor Name
HealthNow
Contractor Number
00801
Contractor Type
Carrier
Article Database ID Number
A19252
Article Type
Detailed Article
Contractor Determination Number
RD001E08
Article Title
Breast Imaging: Mammography/Breast Echography (Sonography)/Breast
MRI/Ductography - 4
Is the AMA CPT / ADA CDT Copyright Statement Required?
Yes
CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. CDT-4 codes and descriptions are (C) 2002, 2004 American Dental Association. All rights reserved.
Primary Geographic Jurisdiction
Upstate New York
Original Article Effective Date
04/07/2004
Article Beginning Effective Date
11/04/2004
Article Revision Effective Date
01/01/2007
Article Ending Effective Date
Coding Guidelines
1. The guidelines of the Correct Coding Initiative (CCI) supersede all
coding instructions in this policy.
2. The diagnosis code(s) must best describe the patient's condition for
which the service was performed.
3. Billed services for which the provider expects a medical necessity
denial should have either the GA (with signed ABN) or GZ (without
signed ABN) modifier attached to the code. If the service is
statutorily non-covered or without benefit category, use the GY
modifier instead.
4. Screening Mammogram
- For dates of service through 12/31/2006, use CPT procedure code
76092 or G0202 and 76083 when reporting a screening mammogram.
For dates of service on or after 01/01/2007, use CPT code 77057
or G0202 and 77052 to report a screening mammogram. These
procedures are inherently bilateral.
- For dates of service through 12/31/2006, when the facility
provides only the technical component, report CPT code 76092 or
G0202 and 76083 with the TC modifier.
- For dates of service through 12/31/2006, when only the
professional component is provided, report CPT code 76092 or
G0202 and 76083 with the 26 modifier. For dates of service on or
after 01/01/2007, when only the professional component is
provided, report CPT code 77057 or G0202 and 77052 with the 26
modifier.
- All screening mammograms must be coded with ICD-9-CM code V76.12
or V76.11.
- CPT procedure code 76092 (for dates of service through
12/31/2006) OR 77057 (for dates of service on or after
01/01/2007) may not be billed together with HCPCS code G0202.
- Only one type of screening mammography is allowed.
- Special billing instructions when the radiologist's
interpretation of a screening mammogram results in additional
views:
Both the screening mammography and the diagnostic mammography may be
reimbursed. Attach the GG modifier to the diagnostic code to show that
the test changed from a screening mammography to a diagnostic
mammography.
The diagnostic mammogram should be billed with one of the ICD-9-CM
codes listed in the LCD under "ICD-9-CM codes that Support Medical
Necessity. For diagnostic mammography and screening mammography that
converts to diagnostic mammography:
The screening mammography should be billed with ICD-9-CM code V76.11
or V76.12 as the "principal diagnosis code" for services rendered
prior to 10/01/2006.
Effective for services rendered on or after 10/01/2006, when the
screening mammography is the only service on the claim, ICD-9-CM code
V76.11 or V76.12 must be reported as the "principal diagnosis code".
Effective for services rendered on or after 10/01/2006, when the
screening mammography is billed on the same claim as other services,
ICD-9-CM code V76.11 or V76.12 does not need to be reported as the
"principal diagnosis code", but must be reported as an additional
diagnosis code on the claim.
The screening and diagnostic mammographies should be billed on the
same claim.
5. Screening mammography CPT codes 76092 or G0202 and 76083 (for dates of
service through 12/31/2006) and 77057 or G0202 and 77052 (for dates of
service on or after 01/01/2007) should be reported whether the
mammography is performed unilaterally or bilaterally. The modifier 52
(reduced services) should be appended to the CPT/HCPCS codes when
performed unilaterally.
Note: When modifier 52 is appended to the screening mammography codes
76092 or G0202 and 76083 (for dates of service through 12/31/2006) and
77057 or G0202 and 77052 (for dates of service on or after
01/01/2007), it would be assumed that the service rendered was a
UNILATERAL mammography. The unilateral mammography would be paid at a
reduced rate.
6. Diagnostic Mammogram
For dates of service through 12/31/2006, use CPT procedure code 76090
or G0206 when reporting unilateral diagnostic mammography. For dates
of service on or after 01/01/2007, use CPT code 77055 or G0206 when
reporting unilateral diagnostic mammography.
For dates of service through 12/31/2006, use CPT procedure code 76091
or G0204. For dates of service on or after 01/01/2007, use CPT code
77056 or G0204 when reporting bilateral diagnostic mammography.
Only one of these codes may be reported for any given date of service.
When the facility provides only the technical component, report CPT
code 76090 or 76091 (for dates of service through 12/31/2006), 77055
or 77056 (for dates of service on or after 01/01/2007), G0204, or
G0206 with the TC modifier.
When only the professional component is provided, report CPT code
76090 or 76091 (for dates of service through 12/31/2006), 77055 or
77056 (for dates of service on or after 01/01/2007), G0204, or G0206
with the 26 modifier.
CPT code 76090, 76091 (for dates of service through 12/31/2006), CPT
code 77055, 77056 (for dates of service on or after 01/01/2007), HCPCS
code G0204 or G0206 may not be billed together. Only one type of
diagnostic mammography is allowed.
7. The following add-on codes must be reported with the appropriate
mammography code:
CPT code 76083 - computer aided detection for screening mammography
(for dates of service through 12/31/2006)
CPT code 77052 - computer aided detection for screening mammography
(for dates of service on or after 01/01/2007)
CPT code 76082 - computer aided detection for diagnostic mammography
(for dates of service through 12/31/2006)
CPT code 77051 - computer aided detection for diagnostic mammography
(for dates of service on or after 01/01/2007)
If just the add-on code is billed, the service will be denied. Both
the add-on code and the appropriate mammography code should be
reported on the same claim.
For dates of service through 12/31/2006), CPT code 76083 must be
billed with the primary code 76092 or G0202.
For dates of service on or after 01/01/2007, CPT code 77052 must be
billed with the primary code 77057 or G0202
For dates of service through 12/31/2006, CPT code 76082 must be billed
with the primary codes 76090, 76091, G0204 or G0206.
For dates of service on or after 01/01/2007, CPT code 77051 must be
billed with the primary codes 77055, 77056, G0204 or G0206.
8. Claims for screening and diagnostic mammograms must include the
6-digit FDA-assigned certification number of the center/facility in
Item 32 of the CMS -1500 claim form, or in the electronic equivalent.
9. When the technical and professional components of mammography are
billed separately, they should be billed to the carrier in whose
jurisdiction each individual component was performed.
10. An evaluation and management (E&M) service or consultantation by the
radiologist on the same day (or subsequent days) as a mammogram,
breast sonogram, MRI, or ductogram, or their components should not be
separately coded or billed.
11. An evaluation and management (E&M) service by a non-radiologist also
performing the components of a mammogram, reported and documented in
the medical record as a separate and distinct service, on the same day
as the mammogram should be coded with modifier -25.
12. Transportation costs for mammography-certified portable x-ray
suppliers providing diagnostic mammography services may be reported
with HCPCS procedure code R0070 or R0075. Transportation must be
reported on the same claim as the diagnostic mammography test.
13. Breast Sonography - Use CPT code 76645 when reporting breast
sonography, unilateral or bilateral. It would be inappropriate to use
a 50 modifier or to increase the units field, as reimbursement for
this code is already based on the procedure being performed
bilaterally. Report 76645 with the TC modifier when only the technical
component is provided. Report 76645 with the 26 modifier when only the
professional component is provided.
14. Breast MRI - Use CPT code 76093 (for dates of service through
12/31/2006) and code 77058 (for dates of service on or after
01/01/2007) when reporting a unilateral breast MRI. Use CPT procedure
code 76094 (for dates of service through 12/31/2006) and code 77059
(for dates of service on or after 01/01/2007) when reporting a
bilateral breast MRI. Only one of these codes may be reported for any
given date of service. When only the technical component is provided,
report 76093 or 76094 (for dates of service through 12/31/2006) and
code 77058 or 77059 (for dates of service on or after 01/01/2007) with
the TC modifier. When only the professional component is provided,
report 76093 or 76094 (for dates of service through 12/31/2006) and
code 77058 or 77059 (for dates of service on or after 01/01/2007) with
the 26 modifier.
15. Mammary Ductogram or Galactogram - Use CPT code 76086 (for dates of
service through 12/31/2006) and code 77053 (for dates of service on or
after 01/01/2007) when reporting a mammary ductogram or galactogram of
a single duct. Use CPT code 76088 (for dates of service through
12/31/2006) and code 77054 (for dates of service on or after
01/01/2007) when reporting a mammary ductogram or galactogram of
multiple ducts. Only one of these codes may be reported for any given
date of service. When only the technical component is provided, report
76086 or 76088 (for dates of service through 12/31/2006) and code
77053 or 77054 (for dates of service on or after 01/01/2007) with the
TC modifier. When only the professional component is provided, report
76086 or 76088 (for dates of service through 12/31/2006) and code
77053 or 77054 (for dates of service on or after 01/01/2007) with the
26 modifier. Use CPT code 19030 for the injection of contrast.
16. Where more than one modifier is necessary (e.g., if the service was
performed in a rural Health Professional Shortage Area facility and a
component modifier is needed), put the mammography modifier (26, GH or
GG) in modifier position 1 and the rural (or other) modifier in
modifier position 2. Where more than two modifiers are necessary e.g.,
QU or QB GH or GG and 26,, use the multiple modifier (modifier 99) on
the line of coding and place all appropriate modifiers in Item 19 when
billing on the CMS-1500 form, or in the electronic equivalent.
17. For diagnostic mammography, breast sonography, breast MRI, and
ductogram, the UPIN/NPI of the treating/ordering physician or
qualified non-physician practitioner is required on the claim.
18. Additional views taken while performing a diagnostic mammography are
part of the mammography service and should not be coded separately.
19. For all dates of service, the correct coding initiative (CCI)
precludes the billing of the following combinations of services on the
same day:
- A bilateral diagnostic mammogram and a unilateral diagnostic
mammogram
- A bilateral breast MRI and a unilateral breast MRI
- A ductogram of a single duct and a ductogram of multiple ducts.
20. Global billing (i.e., for the combined professional and technical
services) for diagnostic tests is allowed only when the billing
physician personally performed or supervised the test, and then only
when both the technical and professional components are done in the
same facility (location). The service should not be billed globally
when the physician purchases the test from an outside supplier. When
diagnostic tests are purchased, the physician must identify the
supplier by name and address, provide the supplier's provider number
and provide the supplier's charge for the test.
21. Places of service - Global and Technical:
Claims reporting the global and technical components of a screening
mammography (codes 76083, 76092, 77052, 77057 and G0202), a diagnostic
mammography (76082,76090, 76091, 77051, 77055, 77056, G0204 and
G0206), a breast sonography (76645), a breast MRI (76093, 76094, 77058
and 77059 ) and a ductography (76086, 76088, 77053 and 77054 ) are
payable in the following places of service: office (11), mobile unit
(15) and independent clinic (49).
When a mobile unit (place of service 15) is sent to other sites such
as a NF, adult home or physician office, the place of service reported
on the claim should be that of the site where the service was
performed such as office (11), nursing facility (32), custodial care
facility (33).
22. Places of Service - Professional:
Claims reporting the professional component (codes 76082-26, 76086-26,
76088-26, 76090-26, 76091-26, 76093-26, 76094-26, 76645-26, 77051-26,
77053-26, 77054-26, 77055-26, 77056-26, 77058-26, 77059-26, G0204-26
and G0206-26) are payable in the following places of service: office
(11), mobile unit (15), inpatient hospital (21), outpatient hospital
(22), emergency room (23) and independent clinic (49).
When a mobile unit (place of service 15) is sent to other sites such
as a SNF, adult home or physician office, the place of service
reported on the claim should be that of the site where the service was
performed such as office (11), Skilled nursing facility (31), nursing
facility (32), custodial care facility (33).
Claims reporting the professional component (codes 76092-26, 76083-26,
77052-26, 77057-26 and G0202-26) are payable in the following places
of service: office (11), mobile unit (15), outpatient hospital (22)and
independent clinic (49).
When a mobile unit (place of service 15) is sent to other sites such
as a SNF, adult home or physician office, the place of service
reported on the claim should be that of the site where the service was
performed such as office (11), Skilled nursing facility (31), nursing
facility (32), custodial care facility (33).
Coverage Topic
Diagnostic Tests and X-Rays
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
Other Comments
For services that exceed the accepted standard of medical practice and may
be deemed not medically necessary, the provider/supplier should provide
the patient with an acceptable advance notice of Medicare's possible
denial of payment. An advance beneficiary notice (ABN) should be signed
when a provider/supplier does not want to accept financial responsibility
for the service.
This Article was converted from an LMRP on 04/07/2004
Revision History Explanation
Revision #4: This article was revised to reflect new CPT codes effective
01/01/2007 as per CR 5327 and 5306.
Revision #3: 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 #2: Added guidelines #2 and 4. Revised guideline #6. Removed outdated information on CPT codes. Added ICD-9CM code V76.11, per CR 3562.
Revision #1: Reformatted Coding Guidelines for clarity. Added new information - Coding Guidelines #7, 8, and 15. Updated descriptor for CPT codes 76090 and 76091.
Does this Article contain a "Least Costly Alternative" provision?
No
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