Mountain State Medical Policy Bulletin |
Section: | Radiology |
Number: | X-21 |
Topic: | Mammography |
Effective Date: | August 1, 2005 |
Issued Date: | August 1, 2005 |
Date Last Reviewed: | 07/2005 |
Indications and Limitations of Coverage
Diagnostic Mammography
Fibrocystic disease, in and of itself, does not warrant medical necessity for a diagnostic mammogram. However, a patient diagnosed with fibrocystic disease and experiencing suspicious changes, signs or symptoms as specified in items #1 through #3 above would be eligible for a diagnostic mammogram (76090, 76091, G0204, or G0206, as appropriate). Screening Mammography Payment is made for one (1) routine screening mammogram per calendar year for asymptomatic women forty years of age or older. Additionally, physician recommended mammograms (i.e., those that are prescribed by a physician) are covered for all other women (under age 40) regardless of the reason performed. (Self-referred screening mammograms for women under age 40 are not covered.) Payment for physician recommended mammograms is not limited to one (1) per year. Coverage for screening mammography is determined according to individual or group customer benefits. Screening Mammography When Additional Views Are Needed If additional views are needed during a screening mammogram to diagnose or confirm a suspicious mammographic lesion, the service is considered a diagnostic mammogram and should be reported and processed as such, whether additional views are taken at the initial imaging session or on a different date of service. Since extra views were obtained to complete a single mammography study, they are not considered or paid as a separate service. Screening and Diagnostic Studies on Same Day
These records should be available for review upon request. Mammography and Computer-Aided Detection (CAD) Both codes 76082 and 76083 are designated as "add-on" codes. Add-on codes are always performed in addition to the primary service or procedure and must never be reported as a stand-alone service. Code 76082 should always be reported with the appropriate diagnostic mammography code 76090 or 76091 as appropriate. Code 76083 should always be reported with the appropriate screening mammography code 76092. There is also a code (S8075) that should be used to report computer analysis of full field digital mammograms with further physician review. Code S8075 should always be reported with mammography codes G0202, G0204, or G0206, as appropriate. Codes 76082, 76083, and S8075 should only be reported with the primary mammography procedure with which it is performed. When reported without the appropriate mammography code, the add-on codes will be denied. A participating, preferred, or network provider cannot bill the member for the denied service in this situation. Refer to Medical Policy Bulletin X-19 for information on xeroradiography (xeromammography). |
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76082 | 76083 | 76090 | 76091 | 76092 | G0202 |
G0204 | G0206 | S8075 |
PRN References 08/1993, Definition of screening vs. diagnostic mammography |