CMS Limitations Guide Mammograms and Bone Density Radiology Services
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- Silvia Riley
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1 CMS Limitations Guide Mammograms and Bone Density Radiology Services Starting July 1, 2008, CMS has placed numerous medical necessity limits on tests and procedures. This reference guide provides you with all of the latest changes. This guide is not an all-inclusive list of National Coverage Documents (NCD) and Local Coverage Documents (LCD). Please consult the CMS website for additional information at cms.hhs.gov/mcd/search.asp?clickon=search. You can search by LCD or NCD or keyword and region. CMS will deny payment if the correct diagnosis codes are not entered on the order form, and your patient s test or procedure will not be covered. We compiled this information in one location to make it easier for you to find the proper codes for medically necessary diagnoses. It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g. to the fourth or fifth digit). The correct use of an ICD-9-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. We will continue to update this list as new CMS limitations are announced. You can always find the most current list on mymunson.org. If you have any questions, please contact Kari Smith, Office Coordinator, at (231) , or Karen Fouch, Manager, Patient Access Services, at (231) Screening Mammograms (L26890)...2 Diagnostic Mammograms (L26890)...3 US Breast & MRI Breast (L26890)...6 Bone Densities (L26385)
2 Screening Mammograms (L26890) V76.11 SCREENING MAMMOGRAM FOR HIGH-RISK PATIENT V76.12 OTHER SCREENING MAMMOGRAM - 2 -
3 Diagnostic Mammograms (L26890) MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST MALIGNANT NEOPLASM OF OVARY SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF AXILLA AND UPPER LIMB SECONDARY MALIGNANT NEOPLASM OF LUNG SECONDARY MALIGNANT NEOPLASM OF MEDIASTINUM SECONDARY MALIGNANT NEOPLASM OF PLEURA MALIGNANT NEOPLASM OF LIVER SECONDARY SECONDARY MALIGNANT NEOPLASM OF SKIN SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW SECONDARY MALIGNANT NEOPLASM OF BREAST DISSEMINATED MALIGNANT NEOPLASM OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE 217 BENIGN NEOPLASM OF BREAST CARCINOMA IN SITU OF SKIN OF TRUNK EXCEPT SCROTUM CARCINOMA IN SITU OF BREAST NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN NEOPLASM OF UNCERTAIN BEHAVIOR OF BREAST NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN NEOPLASM OF UNSPECIFIED NATURE OF BREAST PHLEBITIS AND THROMBOPHLEBITIS OF OTHER SITES SOLITARY CYST OF BREAST - 3 -
4 610.1 DIFFUSE CYSTIC MASTOPATHY FIBROADENOSIS OF BREAST FIBROSCLEROSIS OF BREAST MAMMARY DUCT ECTASIA OTHER SPECIFIED BENIGN MAMMARY DYSPLASIAS BENIGN MAMMARY DYSPLASIA UNSPECIFIED INFLAMMATORY DISEASE OF BREAST HYPERTROPHY OF BREAST FISSURE OF NIPPLE FAT NECROSIS OF BREAST ATROPHY OF BREAST GALACTOCELE GALACTORRHEA NOT ASSOCIATED WITH CHILDBIRTH MASTODYNIA LUMP OR MASS IN BREAST OTHER SIGNS AND SYMPTOMS IN BREAST CAPSULAR CONTRACTURE OF BREAST IMPLANT * OTHER SPECIFIED DISORDERS OF BREAST UNSPECIFIED BREAST DISORDER DEFORMITY OF RECONSTRUCTED BREAST DISPROPORTION OF RECONSTRUCTED BREAST ENLARGEMENT OF LYMPH NODES UNSPECIFIED ABNORMAL MAMMOGRAM MAMMOGRAPHIC MICROCALCIFICATION INCONCLUSIVE MAMMOGRAM OTHER (ABNORMAL) FINDINGS ON RADIOLOGICAL EXAMINATION OF BREAST OPEN WOUND OF BREAST WITHOUT COMPLICATION OPEN WOUND OF BREAST COMPLICATED CONTUSION OF BREAST MECHANICAL COMPLICATION OF BREAST PROSTHESIS INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT V10.3 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST V10.89* PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES V15.89 OTHER SPECIFIED PERSONAL HISTORY PRESENTING HAZARDS TO HEALTH - 4 -
5 V45.83* BREAST IMPLANT REMOVAL STATUS V67.1 FOLLOW-UP EXAMINATION FOLLOWING RADIOTHERAPY V67.2 FOLLOW-UP EXAMINATION FOLLOWING CHEMOTHERAPY V71.1 OBSERVATION FOR SUSPECTED MALIGNANT NEOPLASM *Use ICD-9-CM code for hematoma *ICD-9-CM codes V10.89 and V45.83 may be reported only until clinical stability has been established
6 US Breast & MRI Breast (L26890) MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF AXILLA AND UPPER LIMB SECONDARY MALIGNANT NEOPLASM OF SKIN SECONDARY MALIGNANT NEOPLASM OF BREAST OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE 217 BENIGN NEOPLASM OF BREAST CARCINOMA IN SITU OF BREAST NEOPLASM OF UNCERTAIN BEHAVIOR OF BREAST NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN NEOPLASM OF UNSPECIFIED NATURE OF BREAST 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 DYSPLASIAS 610.9* BENIGN MAMMARY DYSPLASIA UNSPECIFIED INFLAMMATORY DISEASE OF BREAST HYPERTROPHY OF BREAST 611.2* FISSURE OF NIPPLE 611.3* FAT NECROSIS OF BREAST 611.4* ATROPHY OF BREAST - 6 -
7 611.5* GALACTOCELE 611.6* GALACTORRHEA NOT ASSOCIATED WITH CHILDBIRTH MASTODYNIA LUMP OR MASS IN BREAST OTHER SIGNS AND SYMPTOMS IN BREAST * OTHER SPECIFIED DISORDERS OF BREAST 611.9* UNSPECIFIED BREAST DISORDER DEFORMITY OF RECONSTRUCTED BREAST DISPROPORTION OF RECONSTRUCTED BREAST UNSPECIFIED ABNORMAL MAMMOGRAM MAMMOGRAPHIC MICROCALCIFICATION INCONCLUSIVE MAMMOGRAM OTHER (ABNORMAL) FINDINGS ON RADIOLOGICAL EXAMINATION OF BREAST MECHANICAL COMPLICATION OF BREAST PROSTHESIS INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT V10.3 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST - 7 -
8 Bone Densities (L26385) ICD-9-CM code should be reported for collapse of vertebrae NOS. ICD-9-CM code should be reported as a secondary diagnosis when DXA is performed for subsequent monitoring following a BMM performed by another modality. ICD-9-CM code V45.77 should be reported for women s/p oophorectomy. ICD-9-CM code V58.65 should be reported for an individual on glucocorticoid therapy. ICD-9-CM code V58.69 should be reported for DXA testing while taking medicines for osteoporosis/osteopenia. ICD-9-CM code V67.51 should be reported for an individual who has COMPLETED drug therapy for osteoporosis and is being monitored for response to therapy. ICD-9-CM code should be reported to indicate osteopenia, (only when billing DXA), when used to follow treatment with FDA approved osteoporosis medications. For Bone Density CPT Only: CUSHING'S SYNDROME OSTEOPOROSIS UNSPECIFIED SENILE OSTEOPOROSIS IDIOPATHIC OSTEOPOROSIS DISUSE OSTEOPOROSIS OTHER OSTEOPOROSIS DISORDER OF BONE AND CARTILAGE UNSPECIFIED V58.65 LONG-TERM (CURRENT) USE OF STEROIDS V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED These following diagnoses may support medical necessity for CPT codes 77078, 77079, 77080, 77081, 77083, and G0130, when these tests are performed for bone mass density screening for potential osteopenia/osteoporosis in qualified beneficiaries with estrogen deficiency, vertebral abnormalities/fractures, primary hyperparathyroidism or glucocorticoid administration PRIMARY HYPERPARATHYROIDISM POSTABLATIVE OVARIAN FAILURE PREMATURE MENOPAUSE OTHER OVARIAN FAILURE ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED PREMENOPAUSAL MENORRHAGIA POSTMENOPAUSAL BLEEDING SYMPTOMATIC MENOPAUSAL OR FEMALE CLIMACTERIC STATES POSTMENOPAUSAL ATROPHIC VAGINITIS SYMPTOMATIC STATES ASSOCIATED WITH ARTIFICIAL MENOPAUSE - 8 -
9 627.8 OTHER SPECIFIED MENOPAUSAL AND POSTMENOPAUSAL DISORDERS UNSPECIFIED MENOPAUSAL AND POSTMENOPAUSAL DISORDER PATHOLOGICAL FRACTURE OF VERTEBRAE OSTEOGENESIS IMPERFECTA GONADAL DYSGENESIS NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF MUSCULOSKELETAL SYSTEM CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL CLOSED FRACTURE OF FIRST CERVICAL VERTEBRA CLOSED FRACTURE OF SECOND CERVICAL VERTEBRA CLOSED FRACTURE OF THIRD CERVICAL VERTEBRA CLOSED FRACTURE OF FOURTH CERVICAL VERTEBRA CLOSED FRACTURE OF FIFTH CERVICAL VERTEBRA CLOSED FRACTURE OF SIXTH CERVICAL VERTEBRA CLOSED FRACTURE OF SEVENTH CERVICAL VERTEBRA CLOSED FRACTURE OF MULTIPLE CERVICAL VERTEBRAE OPEN FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL OPEN FRACTURE OF FIRST CERVICAL VERTEBRA OPEN FRACTURE OF SECOND CERVICAL VERTEBRA OPEN FRACTURE OF THIRD CERVICAL VERTEBRA OPEN FRACTURE OF FOURTH CERVICAL VERTEBRA OPEN FRACTURE OF FIFTH CERVICAL VERTEBRA OPEN FRACTURE OF SIXTH CERVICAL VERTEBRA OPEN FRACTURE OF SEVENTH CERVICAL VERTEBRA OPEN FRACTURE OF MULTIPLE CERVICAL VERTEBRAE CLOSED FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY OPEN FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY CLOSED FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY OPEN FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITHOUT SPINAL CORD INJURY OPEN FRACTURE OF SACRUM AND COCCYX WITHOUT SPINAL CORD INJURY CLOSED FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF C1-C4 LEVEL WITH COMPLETE LESION OF CORD - 9 -
10 CLOSED FRACTURE OF C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME CLOSED FRACTURE OF C1-C4 LEVEL WITH CENTRAL CORD SYNDROME CLOSED FRACTURE OF C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF C5-C7 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF C5-C7 LEVEL WITH COMPLETE LESION OF CORD CLOSED FRACTURE OF C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME CLOSED FRACTURE OF C5-C7 LEVEL WITH CENTRAL CORD SYNDROME CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF C1-C4 LEVEL WITH COMPLETE LESION OF CORD OPEN FRACTURE OF C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME OPEN FRACTURE OF C1-C4 LEVEL WITH CENTRAL CORD SYNDROME OPEN FRACTURE OF C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF C5-C7 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF C5-C7 LEVEL WITH COMPLETE LESION OF CORD OPEN FRACTURE OF C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME OPEN FRACTURE OF C5-C7 LEVEL WITH CENTRAL CORD SYNDROME OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF T1-T6 LEVEL WITH COMPLETE LESION OF CORD CLOSED FRACTURE OF T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME CLOSED FRACTURE OF T1-T6 LEVEL WITH CENTRAL CORD SYNDROME CLOSED FRACTURE OF T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF T7-T12 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF T7-T12 LEVEL WITH COMPLETE LESION OF CORD CLOSED FRACTURE OF T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME CLOSED FRACTURE OF T7-T12 LEVEL WITH CENTRAL CORD SYNDROME CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF T1-T6 LEVEL WITH COMPLETE LESION OF CORD OPEN FRACTURE OF T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME OPEN FRACTURE OF T1-T6 LEVEL WITH CENTRAL CORD SYNDROME OPEN FRACTURE OF T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF T7-T12 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF T7-T12 LEVEL WITH COMPLETE LESION OF CORD
11 OPEN FRACTURE OF T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME OPEN FRACTURE OF T7-T12 LEVEL WITH CENTRAL CORD SYNDROME OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITH COMPLETE CAUDA EQUINA LESION CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY OPEN FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF SACRUM AND COCCYX WITH COMPLETE CAUDA EQUINA LESION OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY CLOSED FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY E932.0 ADRENAL CORTICAL STEROIDS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE V45.77 ACQUIRED ABSENCE OF ORGAN GENITAL ORGANS V49.81 ASYMPTOMATIC POSTMENOPAUSAL STATUS (AGE-RELATED) (NATURAL) V58.65 LONG-TERM (CURRENT) USE OF STEROIDS
CPT 76977, 77078, 77079, 77080, 77081, 77083, or HCPCS G0130:
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