Radiology Coding Alert

Question: How can I determine whether a diagnosis is payable by Medicare for code 77066? We’ve received a diagnostic mammogram order for a patient with a leaking breast implant.

Michigan Subscriber

Answer: With respect to mammograms, the Centers for Medicare & Medicaid Services (CMS) developed National Coverage Determination (NCD) 220.4 that details which ICD-10-CM codes are reimbursable for both screening and diagnostic mammograms. However, you’ve got to make sure you’re reading from the most updated version of the NCD. CMS will intermittently revise NCDs, and you’ll see that the most recent update to NCD 220.4 was issued in 2018. You can access the NCD at the following link: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2202OTN.pdf

You’ll see the only payable diagnosis for a screening mammogram is Z12.31 (Encounter for screening mammogram for malignant neoplasm of breast). However, the list substantially expands when you’re examining the codes available for diagnostic mammograms. Furthermore, the list of payable diagnoses applies for diagnostic mammograms applies to codes 77065 (Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral) and 77066 (… bilateral).

Your next step is to determine the correct ICD-10-CM code for a leaking breast implant. Leak, leakage ⇒ device, implant or graft ⇒ breast (implant) ⇒ T85.43XA (Leakage of breast prosthesis and implant, initial encounter). Fortunately, you’ll find T85.43XA in the list of covered NCD diagnoses.