CMS Limitations Guide Mammography & Bone Mass ... - Munson Home Care

[Pages:6]CMS Limitations Guide ? Mammography & Bone Mass Measurement

Starting October 1, 2015, CMS will update their existing medical necessity limitations on tests and procedures to correspond to ICD-10 codes. This limitations guide provides you with the latest changes.

This guide is not an all-inclusive list of National Coverage Documents (NCD) and Local Coverage Documents (LCD). You can search by LCD or NCD or keyword and region on the CMS website at: .

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-10-CM. The correct

use of an ICD-10-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 at: medicalnecessity.

If you have any questions, please contact Kari Smith, Office Coordinator, at (231) 935-2296, or Karen Popa, Director, Patient Access Services, at (231) 9357493.

CMS Limitations Guide ? Mammography & Bone Mass Measurement

(NCD 220.4) Diagnostic Mammography

Diagnostic Mammogram (G0206)

ICD-10 Codes That Support Medical Necessity and Covered by Medicare Program:

For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.

Group 1: Code C50.011 C50.012 C50.019 C50.111 C50.112 C50.119 C50.211 C50.212 C50.219 C50.311 C50.312 C50.319 C50.411 C50.412 C50.419 C50.511 C50.512 C50.519 C50.611 C50.612 C50.619 C50.811 C50.812 C50.819 C50.911 C50.912

Description Malignant neoplasm of nipple and areola, right female breast Malignant neoplasm of nipple and areola, left female breast Malignant neoplasm of nipple and areola, unspecified female breast Malignant neoplasm of central portion of right female breast Malignant neoplasm of central portion of left female breast Malignant neoplasm of central portion of unspecified female breast Malignant neoplasm of upper-inner quadrant of right female breast Malignant neoplasm of upper-inner quadrant of left female breast Malignant neoplasm of upper-inner quadrant of unspecified female breast Malignant neoplasm of lower-inner quadrant of right female breast Malignant neoplasm of lower-inner quadrant of left female breast Malignant neoplasm of lower-inner quadrant of unspecified female breast Malignant neoplasm of upper-outer quadrant of right female breast Malignant neoplasm of upper-outer quadrant of left female breast Malignant neoplasm of upper-outer quadrant of unspecified female breast Malignant neoplasm of lower-outer quadrant of right female breast Malignant neoplasm of lower-outer quadrant of left female breast Malignant neoplasm of lower-outer quadrant of unspecified female breast Malignant neoplasm of axillary tail of right female breast Malignant neoplasm of axillary tail of left female breast Malignant neoplasm of axillary tail of unspecified female breast Malignant neoplasm of overlapping sites of right female breast Malignant neoplasm of overlapping sites of left female breast Malignant neoplasm of overlapping sites of unspecified female breast Malignant neoplasm of unspecified site of right female breast Malignant neoplasm of unspecified site of left female breast

CMS Limitations Guide ? Mammography & Bone Mass Measurement

C50.919 C50.021 C50.022 C50.029 C50.121 C50.122 C50.129 C50.221 C50.222 C50.229 C50.321 C50.322 C50.329 C50.421 C50.422 C50.429 C50.521 C50.522 C50.529 C50.621 C50.622 C50.629 C50.821 C50.822 C50.829 C50.921 C50.922 C50.929 C79.2 C79.81 C80.0 C80.1 D24.1 D24.2 D24.9 D04.5 D05.00

Malignant neoplasm of unspecified site of unspecified female breast Malignant neoplasm of nipple and areola, right male breast Malignant neoplasm of nipple and areola, right male breast Malignant neoplasm of nipple and areola, unspecified male breast Malignant neoplasm of central portion of right male breast Malignant neoplasm of central portion of left male breast Malignant neoplasm of central portion of unspecified male breast Malignant neoplasm of upper-inner quadrant of right male breast Malignant neoplasm of upper-inner quadrant of left male breast Malignant neoplasm of upper-inner quadrant of unspecified male breast Malignant neoplasm of lower-inner quadrant of right male breast Malignant neoplasm of lower-inner quadrant of left male breast Malignant neoplasm of lower-inner quadrant of unspecified male breast Malignant neoplasm of upper-outer quadrant of right male breast Malignant neoplasm of upper-outer quadrant of left male breast Malignant neoplasm of upper-outer quadrant of unspecified male breast Malignant neoplasm of lower-ourter quadrant of right male breast Malignant neoplasm of lower-outer quadrant of left male breast Malignant neoplasm of lower-outer quadrant of unspecified male breast Malignant neoplasm of axillary tail of right male breast Malignant neoplasm of axillary tail of left male breast Malignant neoplasm of axillary tail of unspecified male breast Malignant neoplasm of overlapping sites of right male breast Malignant neoplasm of overlapping sites of left male breast Malignant neoplasm of overlapping sites of unspecified male breast Malignant neoplasm of unspecified site of right male breast Malignant neoplasm of unspecified site of left male breast Malignant neoplasm of unspecified site of unspecified male breast Secondary malignant neoplasm of skin Secondary malignant neoplasm of breast Disseminated malignant neoplasm, unspecified Malignant (primary) neoplasm, unspecified Benign neoplasm of right breast Benign neoplasm of left breast Benign neoplasm of unspecified breast Carcinoma in sit of skin of trunk Lobular carcinoma in situ of unspecified breast

CMS Limitations Guide ? Mammography & Bone Mass Measurement

D05.01 D05.02 D05.10 D05.11 D05.12 D05.80 D05.81 D05.82 D05.90 D05.91 D05.92 D48.60 D48.61 D48.62 D49.2 D49.3 I80.8 N60.01 N60.02 N60.09 N60.11 N60.12 N60.19 N60.21 N60.22 N60.29 N60.31 N60.32 N60.39 N60.41 N60.42 N60.49 N60.81 N60.82 N60.89 N60.91 N60.92

Lobular carcinoma in situ of right breast Lobular carcinoma in situ of left breast Intraductal carcinoma in situ of unspecified breast Intraductal carcinoma in situ of right breast Intraductal carcinoma in situ of left breast Other specified type of carcinoma in situ of unspecified breast Other specified type of carcinoma in situ of right breast Other specified type of carcinoma in situ of left breast Unspecified type of carcinoma in situ of unspecified breast Unspecified type of carcinoma in situ of right breast Unspecified type of carcinoma in situ of left breast Neoplasm of uncertain behavior of unspecified breast Neoplasm of uncertain behavior of right breast Neoplasm of uncertain of behavior of left breast Neoplasm of unspecified behavior of bone Neoplasm of unspecified behavior of breast Phlebitis and thrombophlebitis of other sites Solitary cyst of right breast Solitary cyst of left breast Solitary cyst of unspecified breast Diffuse cystic mastopathy of right breast Diffuse cystic mastopathy of left breast Diffuse cystic mastopathy of unspecified breast Fibroadenosis of right breast Fibroadenosis of left breast Fibroadenosis of unspecified breast Fibrosclerosis of right breast Fibrosclerosis of left breast Fibrosclerosis of unspecified breast Mammary duct ectasia of right breast Mammary duct ectasia of left breast Mammary duct ectasia of unspecified breast Other benign mammary dysplasias of right breast Other benign mammary dysplasias of left breast Other benign mammary dysplasias of unspecified breast Unspecified benign mammary dysplasia of right breast Unspecified benign mammary dysplasia of left breast

CMS Limitations Guide ? Mammography & Bone Mass Measurement

N60.99 N61 N62 N64.0 N64.1 N64.2 N64.89 N64.3 N64.4 N63 N64.51 N64.52 N64.53 N64.59 N64.81 N64.82 N64.9 R92.8 R92.0 R92.2 R92.1 S21.001A S21.002A S21.009A S21.011A S21.012A S21.019A S21.031A S21.032A S21.039A S21.051A S21.052A S21.059A S28.211A S28.212A S28.219A S28.221A

Unspecified benign mammary dysplasia of unspecified breast Inflammatory disorders of breast Hypertrophy of breast Fissure and fistula of nipple Fat necrosis of breast Atrophy of breast Other specified disorders of breast Galactorrhea not associated with childbirth Mastodynia Unspecified lump in breast Induration in breast Nipple discharge Retraction of nipple Other signs and symptoms in breast Ptosis of breast Hypoplasia of breast Disorder of breast, unspecified Other abnormal and inconclusive findings on diagnostic imaging of breast Mammographic microcalcification found on diagnostic imaging of breast Inconclusive mammogram Mammographic calcification found on diagnostic imaging of breast Unspecified open wound of right breast, initial encounter Unspecified open wound of left breast, initial encounter Unspecified open wound of unspecified breast, initial encounter Laceration without foreign body of right breast, initial encounter Laceration without foreign body of left breast, initial encounter Laceration without foreign body of unspecified breast, initial encounter Puncture wound without foreign body of right breast, initial encounter Puncture wound without foreign body of left breast, initial encounter Puncture wound without foreign body of unspecified breast, initial encounter Open bite of right breast, initial encounter Open bite of left breast, initial encounter Open bite of unspecified breast, initial encounter Complete traumatic amputation of right breast, initial encounter Complete traumatic amputation of left breast, initial encounter Complete traumatic amputation of unspecified breast, initial encounter Partial traumatic amputation of right breast, initial encounter

CMS Limitations Guide ? Mammography & Bone Mass Measurement

S28.222A S28.229A S21.021A S21.022A S21.029A S21.041A S21.042A S21.049A T85.41XA T85.42XA T85.43XA T85.44XA T85.49XA T85.79XA

Z85.3 Z91.89 Z03.89

Partial traumatic amputation of left breast, initial encounter Partial traumatic amputation of unspecified breast, initial encounter Laceration with foreign body of right breast, initial encounter Laceration with foreign body of left breast, initial encounter Laceration with foreign body of unspecified breast, initial encounter Puncture wound with foreign body of right breast, initial encounter Puncture wound with foreign body of left breast, initial encounter Puncture wound with foreign body of unspecified breast, initial encounter Breakdown (mechanical) of breast prosthesis and implant, initial encounter Displacement of breast prosthesis and implant, initial encounter Leakage of breast prosthesis and implant, initial encounter Capsular contracture of breast implant, initial encounter Other mechanical complication of breast prosthesis and implant, initial encounter Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter Personal history of malignant neoplasm of breast Other specified personal risk factors, NEC Encounter for observation for other suspected diseases and conditions ruled out

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