ICD 10 Coding Alert
Establish Medical Necessity for Screening Breast MRI
Question: How can we report a screening MRI? Our physician wants to schedule a breast MRI for a Medicare patient who is BRCA2 positive. Is this service covered only when medically necessary?
Delaware Subscriber
Answer: From what has been described in the question, it seems unlikely that Medicare will pay for a screening breast MRI.
You will need to confirm if the payer (Medicare in this case) will cover the diagnosis of Z15.01 (Genetic susceptibility to malignant neoplasm of breast) to support the medical need. You msy only use a Factor Influencing Health code as the question indicated she does not have an issue currently other than her BRCA status.
If the documentation supports the presence of tumor markers such as; A-15or ER status, another option may be using ICD- 10-CM code R97.8 (Other abnormal tumor markers). However if only the BRCA is noted, this would not be the correct code. BRCA as it is not a tumor marker.
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