Inpatient Facility Coding & Compliance Alert
Does Medicare Pay for a Screening Breast MRI?
Question: We have a Medicare patient that is BRCA2 positive. Our doctor wants a breast MRI for the patient. I know that Medicare considers this a covered service if it is medically necessary. However, I am not aware of the criteria. Will Medicare pay for a screening breast MRI?
Delaware Subscriber
Answer: Your answer will all depend on whether they cover the diagnosis V84.01 (Genetic susceptibility to malignant neoplasm of breast) in support of medical need.
At the present time, they will not pay for a screening breast MRI, so you have to establish that this is not screening. However, you cannot use a non-V code because she currently apparently does not have an issue except for her BRCA status (unless she found a breast lump or something).
Another option is using a 795.8x code if you also have an abnormal tumor marker (BRCA is not a tumor marker, but CA-15, ER status, etc. are). The BRCA test finds a gene that may increase the risk of cancer.
ICD-10: When you shift to ICD-10, you will report Z15.01 (Genetic susceptibility to malignant neoplasm of breast) instead. If the patient has an elevated CA-15; the ICD-9 code 795.89 (Other abnormal tumor markers) would become R97.8 (Other abnormal tumor markers) in ICD-10.
Inpatient Facility Coding & Compliance Alert
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