Radiology Coding Alert

Question: I received a denial for N61.23 on a bilateral diagnostic mammogram. Am I able to appeal this using medical necessity as justification?

Oregon Subscriber

Answer: Prior to October 30, 2020, billing for codes 77066 (Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral) or 77065 (… unilateral) with ICD-10-CM code N61.23 (Granulomatous mastitis, bilateral breast) would result in a denial. However, the Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 12027 on October 30, 2020, which updated the National Coverage Determination (NCD) for Mammograms (220.4).

Specifically, the CR instructs Medicare Administrative Contractors (MACs) to add the following ICD-10-CM codes to NCD 220.4:

• N61.21 (Granulomatous mastitis, right breast)
• N61.22 (… left breast)
• N61.23 (… bilateral breast)

The NCD 220.4 benefit category includes diagnostic tests (other) and screening mammograms, meaning these added diagnoses are now reimbursable for codes 77066 and 77067. However, MACs may still deny for services billed prior to October 30, 2020. For denials prior to this date, you may attempt to submit an appeal using the updated NCD as justification for reimbursement.