|
Search the FAQs - Search our current and archived FAQs.
CPT codes, descriptors and other data only are copyright 1999
American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.
Diagnostic Tests and X-Rays
1. Will Medicare cover mammograms for males with breast cancer? (Last Reviewed: July 16, 2008)
2. Is a separate order from the physician required for x-rays taken intraoperatively? (Last Reviewed: July 16, 2008)
3. If the radiologist observes abnormalities as he/she is viewing mammography films, he/she may order additional views without an order from the referring physician. If the additional views are taken the same day, the screening mammography becomes a diagnostic study, and the only code we would report is the diagnostic; we would not report the screening. If the patient left the imaging center and returns another day for the additional views, the original mammography may be coded as a screening service and the follow-up session as a diagnostic. Should we add modifier GH with code 76091 to indicate the screening mammography was converted to a diagnostic mammography? (Last Reviewed: July 16, 2008)
4. If something shows up on the annual mammography and a 6-month follow-up is recommended: Once the 6-month follow-up is done and everything is okay, when is the annual mammography done? Should you use the screening mammography or the diagnostic mammography? (Last Reviewed: July 16, 2008)
5. Under what conditions will Medicare cover mammography as a diagnostic service? (Last Reviewed: April 25, 2008)
6. If an internist writes an order for an x-ray, but the oncologist at the testing facility thinks the patient should have a bone scan instead, does the oncologist need to write a new order? (Last Reviewed: April 25, 2008)
1. Will Medicare cover mammograms for males with breast cancer? (Last Reviewed: July 16, 2008)
On the Centers for Medicare & Medicaid Services (CMS) preventive services Web page, www.cms.hhs.gov/Mammography/06_coding_bill.asp#TopOfPage, you will find that Medicare covers:
- All women with Medicare ages 40 and older are eligible to receive a screening mammogram every 12 months. Medicare also covers digital technologies for screening mammograms.
- Medicare pays for one baseline mammogram for women with Medicare between ages 35 and 39.
- A doctor's prescription or referral is not necessary for Medicare payment of screening mammograms.
- There is no Part B deductible, but a 20 percent coinsurance or co-payment applies.
A diagnostic mammogram is a covered radiological procedure that is furnished to a man or woman with signs or symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and it includes a physician's interpretation of the results of the procedure. Unlike the screening mammogram, the diagnostic procedure does require a doctor's prescription or referral in order for coverage to be available.
As stated in Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §220.4:
A radiological mammogram is a covered diagnostic test under the following conditions:
- A patient has distinct signs and symptoms for which a mammogram is indicated;
- A patient has a history of breast cancer; or
- A patient is asymptomatic but, on the basis of the patient's history and other factors the physician considers significant, the physician's judgment is that a mammogram is appropriate.
According to current Medicare policy, Medicare will cover a diagnostic mammogram for a male with breast cancer. You may also refer to Pub. 100-02, Medicare Benefit Policy Manual, Chapter 1, §50, and Chapter 15, §§80.6 and 280.3.
2. Is a separate order from the physician required for x-rays taken intraoperatively? (Last Reviewed: July 16, 2008)
No. A separate order for x-rays is not needed when x-rays are taken intraoperatively. The provider must document in the patient's record that the x-rays were taken during the surgical procedure. It would be inferred that the service was medically necessary during inpatient surgery. Please review the following reference materials: Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.6 through 80.6.5 and the March 2003 Medicare B Hotline Bulletin, "Ordering Diagnostic Tests."
3. If the radiologist observes abnormalities as he/she is viewing mammography films, he/she may order additional views without an order from the referring physician. If the additional views are taken the same day, the screening mammography becomes a diagnostic study, and the only code we would report is the diagnostic; we would not report the screening. If the patient left the imaging center and returns another day for the additional views, the original mammography may be coded as a screening service and the follow-up session as a diagnostic. Should we add modifier GH with code 76091 to indicate the screening mammography was converted to a diagnostic mammography? (Last Reviewed: July 16, 2008)
In this scenario, if the patient comes in for a screening mammography and it becomes a diagnostic study on the same day, bill the diagnostic code with the GG modifier per instructions in Pub. 100-04, Medicare Claims Processing Manual, Chapter 18, §20.2. If the patient comes back another day for additional diagnostic services, no modifier is necessary.
4. If something shows up on the annual mammography and a 6-month follow-up is recommended: Once the 6-month follow-up is done and everything is okay, when is the annual mammography done? Should you use the screening mammography or the diagnostic mammography? (Last Reviewed: July 16, 2008)
Once clinical stability has been established and the patient is no longer considered at risk, return to the screening mammography. According to Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §280.3, "The term "screening mammography" means a radiologic procedure provided to an asymptomatic woman for the purpose of early detection of breast cancer and includes a physician's interpretation of the results of the procedure."
The annual will begin 12 months after the most recent screening mammography. For a woman over 39, Medicare pays for a screening mammography performed after 11 full months have passed following the month in which the last screening mammography was performed. "To determine the 11-month period, intermediaries and carriers start counting beginning with the month after the month in which a previous screening mammography was performed."
For information on diagnostic mammography, please refer to Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §220.4.
5. Under what conditions will Medicare cover mammography as a diagnostic service? (Last Reviewed: April 25, 2008)
Per the Breast Imaging Local Coverage Determination (LCD) #RD001E08 (Database #L3761), which can be referenced on our Web site at www.umd.nycpic.com/lcdcopy.html, diagnostic mammogram is indicated when: (1) When there are signs or symptoms suggestive of malignancy (e.g., a 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 mammogram; (3) There is short interval follow-up (at six months intervals, for 2 years) necessary for unresolved clinical/radiographic concerns; or diagnostic breast evaluation may be indicated in cases of a personal history of malignancy and in cases of benign biopsy-proven breast disease; (4) Once clinical stability has been established, the routine use of diagnostic mammogram over screening mammogram 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.
6. If an internist writes an order for an x-ray, but the oncologist at the testing facility thinks the patient should have a bone scan instead, does the oncologist need to write a new order? (Last Reviewed: April 25, 2008)
No. When an interpreting physician (e.g., radiologist, cardiologist, family practitioner, general internist, neurologist, obstetrician, gynecologist, ophthalmologist, thoracic surgeon, vascular surgeon) at a testing facility determines that an ordered diagnostic radiology test is clinically inappropriate or suboptimal, and that a different diagnostic test should be performed (e.g., an MRI should be performed instead of a CT scan because of the clinical indication), the interpreting physician and/or testing facility may not perform the unordered test until a new order from the treating physician and/or practitioner has been received. Similarly, if the result of an ordered diagnostic test is normal and the interpreting physician believes that another diagnostic test should be performed (e.g., a renal sonogram was normal and based on the clinical indication, the interpreting physician believes an MRI will reveal the diagnosis), an order from the treating physician must be received prior to performing the unordered diagnostic test. (Reference: Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §§80.6.2 and 80.6.3.)
Search the FAQs - This search function will search only the FAQs portion of our Web site.
Please Note: This search engine utilizes Javascript. You must have Javascript enabled in order to use this search engine. If you do not have Javascript enabled, please consider using the Bulletin and Local Medical Review Policy searches found on the "Search/Site Map" section of our Web site.
Additional FAQs can be found by visiting the FAQs section of the Centers for Medicare & Medicaid Services (CMS) Web site. CMS FAQs cover a wide range of Medicare-related topics, and are searchable by category and topic. |
 |
Diagnostic Tests and X-Rays