Radiology Coding Alert
Check Payer Preferences For Screening MRI
Question: Our physician wants to schedule a breast MRI for a Medicare patient who is BRCA2 positive. According to Medicare this service is covered only if it is medically necessary. Can we submit a Medicare claim for this screening MRI?
Delaware Subscriber
Answer: According to the description shared, Medicare will not pay for a screening breast MRI. You have to establish that this is not screening.
You will need to confirm if the payer (Medicare in this case) will cover the diagnosis V84.01 (Genetic susceptibility to malignant neoplasm of breast) in support of medical need. However, you cannot use a non-V code because she currently apparently does not have an issue except for her BRCA status, say for example, a breast lump or breast tenderness.
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 had an elevated CA-15, code 795.89 (Other abnormal tumor markers) becomes R97.8 (Other abnormal tumor markers).
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Check Payer Preferences For Screening MRI
Question: Our physician wants to schedule a breast MRI for a Medicare patient who is BRCA2 [...]
