Radiology Coding Alert

Question: A patient, who is currently receiving treatment for right breast cancer, visited our radiology practice for bilateral diagnostic digital breast tomosynthesis and bilateral diagnostic mammography. We billed G0279-TC and 77066-TC with a C50.911 diagnosis code. The G code was paid, but the mammography code was denied for national coverage determination (NCD).

The NCD states the code will be reimbursed for a patient with a personal history of breast cancer. How should we correct this claim?

Texas Subscriber

Answer: You’ll want to start by reviewing the patient’s medical record to check if the malignant neoplasm is specified. Currently, your claim has C50.911 (Malignant neoplasm of unspecified site of right female breast) connected to G0279 (Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066)) and 77066 (Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral).

While the NCD does include “a personal history of breast cancer” as a coverage reason for diagnostic mammography, using a personal history code like Z85.3 (Personal history of malignant neoplasm of breast) is incorrect in this case because the patient is currently receiving cancer treatment. The NCD also includes “signs and symptoms of breast disease” as a coverage reason for the procedure, which is justified by the patient’s diagnosis.

However, code C50.911 is an unspecified diagnosis code, which may be the reason why you’re receiving a denial. By adjusting the ICD-10-CM code to a more specific diagnosis, such as C50.511 (Malignant neoplasm of lower-outer quadrant of right female breast), you’ll show the medical necessity for the two imaging exams.

Of course, if the patient’s medical record doesn’t list a specific malignancy, query the provider.

Resource: Review the mammogram Medicare NCD at www.cms.gov/medicare-coverage-database/view/ncd. aspx?NCDId=186.