Article - Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography (A52849)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography (L33585).Coding Information: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 UPIN or 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.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.An evaluation and management (E&M) service or consultation by the radiologist on the same day (or subsequent days) as a breast sonogram, MRI, or ductogram or their components should not be separately coded or billed.For breast sonography, breast MRI, and ductogram, the NPI of the treating/ordering physician or qualified non-physician practitioner is required on the claim. Report this number in item 17a of the CMS-1500 form or in the electronic equivalent.BREAST SONOGRAPHYIf performed bilaterally, a modifier 50 may be reported with CPT code 76641 or 76642.BREAST MRIOnly CPT codes77046, 77047, 77048, 77049may be reported for any given date of service.MAMMARY DUCTOGRAM OR GALACTOGRAMOnly CPT code 77053 or 77054 may be reported for any given date of service.Use CPT code 19030 for the injection of contrast.For claims submitted to the Part A MAC:CPT code 19030 is a packaged service and is not separately payable.BREAST SONOGRAPHYFor Part A billing of breast sonography, use the following:CPT codes 76641 and 76642BREAST MRIFor Part A billing of breast MRI, use the following:HCPCS code C8903,C8905, C8906, C8908CPT codes 77046 and 77047DUCTOGRAPHYFor Part A billing of ductography, use the following:CPT codes 77053 or 77054Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.A clear, clinical indication for the breast sonogram/breast MRI/ductogram must be documented in the medical record, as well as in the referral order.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.Documentation must be available to Medicare upon request.