Local Coverage Determination (LCD): Screening and Diagnostic Mammography (L29328)

Transcription

1 Local Coverage Determination (LCD): Screening and Diagnostic Mammography (L29328) Contractor Information Contractor Name First Coast Service Options, Inc. LCD Information Document Information LCD ID L29328 LCD Title Screening and Diagnostic Mammography AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights Original Effective Date For services performed on or after 02/02/2009 Revision Effective Date For services performed on or after 01/01/2015 Revision Ending Date Retirement Date Notice Period Start Date Notice Period End Date

2 reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources:. 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 states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury.. 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.. 21 CFR part 900, subpart B. This section implements FDA certification requirements for suppliers of mammography services.. Balanced Budget Act of 1997, Section 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 , Medicare Benefit Manual, Chapter 15, 280.3

3 CMS Manual System, Pub , Medicare National Determination Manual, Chapter 1, Part 4, CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 18, 20 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Screening Mammogram A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection breast cancer, or a personal history. A screening mammogram does not require a physician s referral, however, detection of a radiographic abnormality, may prompt the interpreting radiologist to order additional views on the same day. When this is the case, the mammography is no longer considered to be a screening exam and should be reported as a diagnostic mammogram. Radiologists who order additional tests must refer back to the treating physician or qualified non-physician practitioner for his/her UPIN and report back to the treating physician the condition of the patient. No separate reimbursement will be made for additional views. The cost for additional views is included in the cost of the diagnostic mammography service. Medicare beneficiaries are allowed screening mammogram(s) (digital and non-digital) for the following indications: Women ages 40 and older are eligible to receive a screening mammogram (digital and non digital) every 12 months Women with Medicare between the ages of 35 and 39 are eligible to received one baseline mammogram Services will only be allowed if supplied by certified suppliers or FDA-certified mammography centers. Limitations The mammogram must consist of at least a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast. Screening mammograms are not allowed on women under age 35. Screening mammograms performed prior to 11 months lapsing following the month in which the last screening mammography service was rendered is noncovered. Facilities that perform screening mammography services may not release screening mammography x-rays for interpretation to physicians who are not approved under the facility s 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

4 next screening mammography will be performed.] Diagnostic Mammography A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician s interpretation of the results of the procedure. Diagnostic mammogram(s) are allowed for the following indications: - the patient is under the care of the referring/ordering physician or qualified non-physican practitioner; - there are signs and/or symptoms suggestive of malignancy (mass, some types of spontaneous nipple discharge or skin changes); - there are possible radiographic abnormalities detected on screening mammography; - there is short interval follow-up (less than one year) necessary for unresolved clinical/radiographic concerns; or - follow-up of established history of a malignancy is necessary Diagnostic breast evaluation may be indicated in cases of a personal history of malignancy and in cases of benign biopsy-proven breast disease. These diagnoses should not, however, routinely warrant a diagnostic mammography. A breast implant does not necessarily imply that a mammogram is diagnostic in nature. Although additional views may be needed, these additional views do not necessarily constitute a diagnostic mammogram, unless there are specific findings that require investigation. Medicare Part B covers diagnostic mammography services if they are furnished by a facility that meets the certification requirements of section 354 of the Public Health Service Act (PHS Act), as implemented by 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. A physician (or qualified non-physician practitioner) referral is required for diagnostic mammography. The patient must be under the care of the physician (or qualified non-physician practitioner) who orders the procedure. The order should specify the diagnosis prompting the referral for a diagnostic mammogram. Diagnostic mammography should be performed under the direct, on-site supervision of an

5 interpreting physician qualified in mammography. 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. 999x Not Applicable 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 Not Applicable CPT/HCPCS Codes Group 1 Paragraph: Group 1 Codes: COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER REVIEW FOR INTERPRETATION, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES; DIAGNOSTIC MAMMOGRAPHY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER REVIEW FOR INTERPRETATION, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES; SCREENING MAMMOGRAPHY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) MAMMOGRAPHY; UNILATERAL MAMMOGRAPHY; BILATERAL

6 SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF EACH BREAST) SCREENING DIGITAL BREAST TOMOSYNTHESIS, BILATERAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) SCREENING MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, G0202 BILATERAL, ALL VIEWS DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT 2-D DIGITAL IMAGE, G0204 BILATERAL, ALL VIEWS DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT 2-D DIGITAL IMAGE, G0206 UNILATERAL, ALL VIEWS DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS, UNILATERAL OR G0279 BILATERAL (LIST SEPARATELY IN ADDITION TO G0204 OR G0206) ICD-9 Codes that Support Medical Necessity Group 1 Paragraph: For screening mammography (77057, or G0202): For claims with dates of service on or after January 1, 2002, when a screening mammography and a diagnostic mammography are performed on the same date of service, for the same patient, append modifier -GG to the diagnostic mammography procedure code. Both the screening mammography and the diagnostic mammography procedure codes should be reported on the same claim: Group 1 Codes: V76.11 SCREENING MAMMOGRAM FOR HIGH-RISK PATIENT V76.12 OTHER SCREENING MAMMOGRAM Group 2 Paragraph: Group 2 Codes: V76.12* OTHER SCREENING MAMMOGRAM Group 2 Medical Necessity ICD-9 Codes Asterisk Explanation: **Diagnosis V76.12 should be reported on the detail line associated with the screening procedure, and one of the below diagnosis codes should be reported on the detail line associated with the diagnostic procedure and modifier GG. Group 3 Paragraph: For diagnostic mammography (77055, 77056, G0204, G0206 or G0279) billed with or without Modifier GG: Group 3 Codes: MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE

7 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 217 BENIGN NEOPLASM OF BREAST CARCINOMA IN SITU OF SKIN OF TRUNK EXCEPT SCROTUM 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 PHLEBITIS AND THROMBOPHLEBITIS OF OTHER SITES SOLITARY CYST OF BREAST - 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 PTOSIS OF BREAST HYPOPLASIA OF BREAST CAPSULAR CONTRACTURE OF BREAST IMPLANT OTHER SPECIFIED DISORDERS OF BREAST UNSPECIFIED ABNORMAL MAMMOGRAM MAMMOGRAPHIC MICROCALCIFICATION INCONCLUSIVE MAMMOGRAM OTHER (ABNORMAL) FINDINGS ON RADIOLOGICAL EXAMINATION OF BREAST V10.3 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST ICD-9 Codes that DO NOT Support Medical Necessity Paragraph: Codes: XX000 Not Applicable

8 General Information Associated Information Documentation Requirements:. Documentation supporting the medical necessity, of a diagnostic mammogram, such as ICD-9- CM diagnosis codes, progress notes, etc., must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.. A clear, clinical indication for the diagnostic mammogram must be documented in the medical record as well as in the referral order. When a diagnostic mammogram is ordered, the medical records must clearly support that the patient is under the care of the referring physician or qualified non-physician practitioner.. The medical record must include a formal written report describing all the views completed.. A physician's order for the diagnostic mammography must be on file in the medical record. The physician's order must include the clinical reason for the referral.. 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 -GG modifier must be documented on the claim line with the procedure code for a diagnostic mammogram.. Documentation must be made available to Medicare upon request. Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to medical review. Sources of Information and Basis for Decision National Guideline Clearinghouse (2008) Screening mammography for women 40 to 49 years of age: a clinical practice guideline from the American College of Physicians. Retrieved from on November 17, National Guideline Clearinghouse (2008) Diagnosis of breast disease. Retrieved from on November 17, 2008 National Comprehensive Cancer Network (2008) NCCN Clinical Practice Guidelines in Oncology TM Breast cancer screening and diagnosis guidelines. V retrieved from on November 17, 2008

9 National Comprehensive Cancer Network (2008) NCCN Clinical Practice Guidelines in Oncology TM Breast Cancer Risk Reduction v Retrieved from on November 17, 2008 Revision History Information Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row. Revision History Date 01/01/2015 R3 Revision History Number Revision History Explanation Revision Number: 7 Publication: December 2014 Connection LCR B Explanation of revision: Annual 2015 HCPCS Update. Descriptor revised for HCPCS codes G0204 and G0206. In addition, added CPT and HCPCS code G0279. The effective date of this revision is based on date of service. Revision Number: 6 Publication: April 2013 Connection LCR B Reason(s) for Change Revisions Due To CPT/HCPCS Code Changes 04/12/2013 R2 03/11/2013 R1 Explanation of revision: LCD revised to clarify reporting of Modifier GG in the ICD-9 Codes that Support Medical Necessity section of the LCD, based on the Medicare Claims Processing Manual. The effective date of this revision is for claims processed on or after 04/12/2013, for dates of service on or after 01/01/02. Revision Number:5 Start Date Revof Comment Period: Start Date of Notice Period:01/24/2013 Original Effective Date:03/11/2013 LCR B January 2013 Connection Explanation of revision: LCD revised to remove instructions for Modifier GH and Provider Education/Guidance

10 include instructions for Modifier GG in the CPT/HCPCS Codes and Documentation Requirements section of the LCD, based on the Medicare Claims Processing Manual. The effective date of this revision is for claims processed on or after 03/11/2013, for dates of service on or after 01/01/02. Revision Number:4 Start Date of Comment Period: Start Date of Notice Period:01/01/2013 Original Effective Date:01/01/2013 LCR B December 2012 Connection Explanation of revision: Annual 2013 HCPCS Update. Descriptor revised for CPT codes and The effective date of this revision is based on date of service. Revision Number:3 Start Date of Comment Period: Start Date of Notice Period: Revised Effective Date:11/04/2010 LCR B Explanation of Revision: Added new language to Documentation Requirement Section of a diagnostic mammogram added. The effective date of this revision is based on date of service. Revision Number:2 Start Date of Comment Period: Start Date of Notice Period:10/01/2009 Revised Effective Date: 10/01/2009 LCR B September 2009 Update Explanation of Revision: Annual 2010 ICD-9-CM Update. Added diagnosis code

11 for procedure codes 77055, 77056, G0204, or G0206. Descriptor revised for diagnosis code for procedure codes 77055, 77056, G0204, and G0206. The effective date of this revision is based on date of service. Revision Number:1 Start Date of Comment Period:02/20/2009 Start Date of Notice Period:05/01/2009 Revised Effective Date: 06/30/2009 LCR B April 2009 Update Explanation of Revision: LCD revised to clarify indications and limitations for screening and diagnostic mammography. New technology codes added to the CPT/HCPCS Codes section of the LCD and CPT code was deleted from the CPT/HCPCS Codes section of the LCD. Revised Documentation Requirements section regarding documentation of ordering/referring physician of diagnostic mammograms. Title of LCD changed to reflect coverage for screening and diagnostic mammography procedures. Contractor s Determination Number was added to the LCD. The effective date of this revision is based on date of service. Revision Number:Original Start Date of Comment Period: Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009 LCR B2009- December 2008 Bulletin This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and

12 FCSO). For Florida (00590) there was no previous LCD on this subject. This document (L29328) is effective on 02/02/ /08/ This policy was updated by the ICD Annual Update. 11/21/ For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group 1 11/25/ For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: descriptor was changed in Group descriptor was changed in Group 1 Associated Documents Attachments Codng Guidelines effec 1/1/15 (PDF KB ) Related Local Coverage Documents Related National Coverage Documents Public Version(s) Updated on 12/11/2014 with effective dates 01/01/ Updated on 07/01/2014 with effective dates 04/12/ /31/2014 Updated on 04/08/2013 with effective dates 04/12/2013 -

13 Screening and Diagnostic Mammography Part B Form Date: 12/22/08 Page 1 of MP Part B Draft LCD FIRST COAST SERVICE OPTIONS CODING GUIDELINES LCD Database ID Number L29328 Florida L Puerto Rico/Virgin Islands Contractor Name First Coast Service Options, Inc. Contractor Number Florida Puerto Rico Virgin Islands LCD Title Screening and Diagnostic Mammography Coding Guidelines There is no Part B deductible for screening mammographies, however, coinsurance is applicable. The purchased service limit on ph ysician billing for diagnostic tests does not apply to these services. A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while the beneficiary is still at the facility for the screening exam. Where a radiologist interpretation results in additional films, the mammography is no longer considered a screening exam for application of age and frequency standards or for payment purposes. This can be done without an additional order from the treating physician. For claims with dates of service on or after January 1, 2002, when a screening mammography turns to a diagnostic mammography for the same patient on the same day, append modifier -GG to the diagnostic mammography code. Both codes should be on the same claim. Comments Revision History Date Revision 01/01/ The coding guideline has been revised to remove outdated language. The effective date of this revision is based on date of service. Screening and Diagnostic Mammography.2

14 Form Date: 12/22/08 Page 2 of MP Part B Draft LCD 03/11/ The c oding gu idelines were revised to update instructions for modifiers GH and GG, based on the Medicare Claims Processing Manual. The effective date of this revision is for claims processed on or after 03/11/2013 for dates of service on or after 01/01/02. 06/30/20 09 Original Document formatted: 12/ 11 /2014 (SW/et /)