Highmark Medicare Advantage Medical Policy in West Virginia

Section: CMS National Guidelines
Number: N-64
Topic: Mammography - NCD 220.4
Effective Date: February 21, 2011
Issued Date: February 21, 2011

General Policy

Screening Mammography
A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician’s interpretation of the results of the procedure. A screening mammography has limitations as it must be, at a minimum, a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast.

Diagnostic Mammography
A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, a personal history of breast cancer, or a personal history of biopsy-proven benign disease, and includes a physician’s interpretation of the results of the procedure.

Indications and Limitations of Coverage

Screening Mammography (77057, G0202)
The following guidelines apply to screening mammograms:

The 11-month period is calculated by counting beginning with the month after the month in which a previous screening mammography was performed.

Unlike diagnostic mammographies, there do not need to be signs, symptoms, or history of breast disease in order for the exam to be covered. Screening mammograms should be reported with diagnosis code V76.11 or V76.12.

A doctor’s prescription or referral is not necessary for the procedure to be covered. Payment may be made for a screening mammography furnished to a woman at her direct request, and based on a woman’s age and statutory frequency parameter.

Mammography facilities that perform screening mammograms are NOT to 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 unless the patient has moved to another part of the country where the next screening mammography will be performed. Interpretations are to be performed ONLY by physicians who are associated with the certified mammography facility. 

Diagnostic Mammography (77055, 77056, G0204 or G0206)
A radiological mammogram is a covered diagnostic test under the following conditions:

A diagnostic mammography must ordered by a doctor of medicine or osteopathy.

Screening Mammography/Diagnostic Mammography – Same Day
When a screening mammography changes to a diagnostic mammography on the same date of service, both services are eligible for reimbursement. Modifier -GG is required when a diagnostic mammogram is performed on the same day as a screening mammogram. If the modifier is missing, the claim will be denied because the required modifier was not submitted. The claim can be resubmitted for consideration with the appropriate modifier.

Computer-Aided Detection (CAD) (77051 or 77052)
Computer-aided detection (CAD), “Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation with or without digitization of film radiographic images” can be billed in conjunction with primary screening mammograms using code 77052 for screening mammograms or using code 77051 for diagnostic mammograms.

The medical necessity criteria outlined above also applies to the CAD (77051 or 77052) when reported in conjunction with either a screening or diagnostic mammogram.

Mammography related CAD equipment does not require FDA certification. Mammography utilizes a direct x-ray of the breast. By contrast, the CAD process uses laser beam to scan the mammography film from a film (analog) mammography, converts it into digital data for the computer, and analyzes the video display for areas suspicious for cancer. The CAD process used with digital mammography analyzes the data from the mammography on a video display for suspicious areas. The patient is not required to be present for the CAD process.

Reasons for Noncoverage

Services are not eligible when performed in a facility that is not FDA-certified.

Computer-aided detection reported independent of the primary procedure, whether screening or diagnostic, will be denied.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

7705177052770557705677057G0202
G0204G0206    

Coding Guidelines

Use code 77051 with codes 77055, 77056, G0204, or G0206 to report computer-aided detection applied to a diagnostic mammogram.

Use code 77052 with codes 77057 or G0202 to report computer-aided detection applied to a screening mammogram.

Use codes 77055 (unilateral) and 77056 (bilateral) to report a diagnostic mammogram.

Use code 77057 to report a bilateral screening mammogram.

Use code G0202 to report a screening mammogram, producing direct digital images.

Use codes G0204 (bilateral) or G0206 (unilateral) to report diagnostic mammograms, producing direct digital images.

Publications

References

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-02, Chapter 1, Section 50

CMS Online Manual Pub. 100-02, Chapter 15, Sections 80, 280.3

CMS Online Manual Pub. 100-03, Section 220.4

CMS Online Manual Pub. 100-04, Chapter 18, Sections 20.1, 20.1.3, 20.2.1, 20.2.1.1, 20.7

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

The following diagnosis codes apply to Screening Mammograms (77052, 77057, and G0202)

V76.11V76.12  

Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.