CMS Limitations Guide Mammography & Bone Mass Measurement
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1 Starting October 1, 2015, CMS will update their existing medical necessity limitations on tests and procedures to correspond to ICD-10 codes. This limitations guide provides you with the latest changes. This guide is not an all-inclusive list of National Coverage Documents (NCD) and Local Coverage Documents (LCD). You can search by LCD or NCD or keyword and region on the CMS website at: CMS will deny payment if the correct diagnosis codes are not entered on the order form, and your patient s test or procedure will not be covered. We compiled this information in one location to make it easier for you to find the proper codes for medically necessary diagnoses. It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination. We will continue to update this list as new CMS limitations are announced. You can always find the most current list at: If you have any questions, please contact Kari Smith, Office Coordinator, at (231) , or Karen Popa, Director, Patient Access Services, at (231)
2 (NCD 220.4) Diagnostic Mammography Diagnostic Mammogram (G0206) ICD-10 Codes That Support Medical Necessity and Covered by Medicare Program: For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used. Group 1: Code Description C Malignant neoplasm of nipple and areola, right female breast C Malignant neoplasm of nipple and areola, left female breast C Malignant neoplasm of nipple and areola, unspecified female breast C Malignant neoplasm of central portion of right female breast C Malignant neoplasm of central portion of left female breast C Malignant neoplasm of central portion of unspecified female breast C Malignant neoplasm of upper-inner quadrant of right female breast C Malignant neoplasm of upper-inner quadrant of left female breast C Malignant neoplasm of upper-inner quadrant of unspecified female breast C Malignant neoplasm of lower-inner quadrant of right female breast C Malignant neoplasm of lower-inner quadrant of left female breast C Malignant neoplasm of lower-inner quadrant of unspecified female breast C Malignant neoplasm of upper-outer quadrant of right female breast C Malignant neoplasm of upper-outer quadrant of left female breast C Malignant neoplasm of upper-outer quadrant of unspecified female breast C Malignant neoplasm of lower-outer quadrant of right female breast C Malignant neoplasm of lower-outer quadrant of left female breast C Malignant neoplasm of lower-outer quadrant of unspecified female breast C Malignant neoplasm of axillary tail of right female breast C Malignant neoplasm of axillary tail of left female breast C Malignant neoplasm of axillary tail of unspecified female breast C Malignant neoplasm of overlapping sites of right female breast C Malignant neoplasm of overlapping sites of left female breast C Malignant neoplasm of overlapping sites of unspecified female breast C Malignant neoplasm of unspecified site of right female breast C Malignant neoplasm of unspecified site of left female breast
3 C Malignant neoplasm of unspecified site of unspecified female breast C Malignant neoplasm of nipple and areola, right male breast C Malignant neoplasm of nipple and areola, right male breast C Malignant neoplasm of nipple and areola, unspecified male breast C Malignant neoplasm of central portion of right male breast C Malignant neoplasm of central portion of left male breast C Malignant neoplasm of central portion of unspecified male breast C Malignant neoplasm of upper-inner quadrant of right male breast C Malignant neoplasm of upper-inner quadrant of left male breast C Malignant neoplasm of upper-inner quadrant of unspecified male breast C Malignant neoplasm of lower-inner quadrant of right male breast C Malignant neoplasm of lower-inner quadrant of left male breast C Malignant neoplasm of lower-inner quadrant of unspecified male breast C Malignant neoplasm of upper-outer quadrant of right male breast C Malignant neoplasm of upper-outer quadrant of left male breast C Malignant neoplasm of upper-outer quadrant of unspecified male breast C Malignant neoplasm of lower-ourter quadrant of right male breast C Malignant neoplasm of lower-outer quadrant of left male breast C Malignant neoplasm of lower-outer quadrant of unspecified male breast C Malignant neoplasm of axillary tail of right male breast C Malignant neoplasm of axillary tail of left male breast C Malignant neoplasm of axillary tail of unspecified male breast C Malignant neoplasm of overlapping sites of right male breast C Malignant neoplasm of overlapping sites of left male breast C Malignant neoplasm of overlapping sites of unspecified male breast C Malignant neoplasm of unspecified site of right male breast C Malignant neoplasm of unspecified site of left male breast C Malignant neoplasm of unspecified site of unspecified male breast C79.2 Secondary malignant neoplasm of skin C79.81 Secondary malignant neoplasm of breast C80.0 Disseminated malignant neoplasm, unspecified C80.1 Malignant (primary) neoplasm, unspecified D24.1 Benign neoplasm of right breast D24.2 Benign neoplasm of left breast D24.9 Benign neoplasm of unspecified breast D04.5 Carcinoma in sit of skin of trunk D05.00 Lobular carcinoma in situ of unspecified breast
4 D05.01 Lobular carcinoma in situ of right breast D05.02 Lobular carcinoma in situ of left breast D05.10 Intraductal carcinoma in situ of unspecified breast D05.11 Intraductal carcinoma in situ of right breast D05.12 Intraductal carcinoma in situ of left breast D05.80 Other specified type of carcinoma in situ of unspecified breast D05.81 Other specified type of carcinoma in situ of right breast D05.82 Other specified type of carcinoma in situ of left breast D05.90 Unspecified type of carcinoma in situ of unspecified breast D05.91 Unspecified type of carcinoma in situ of right breast D05.92 Unspecified type of carcinoma in situ of left breast D48.60 Neoplasm of uncertain behavior of unspecified breast D48.61 Neoplasm of uncertain behavior of right breast D48.62 Neoplasm of uncertain of behavior of left breast D49.2 Neoplasm of unspecified behavior of bone D49.3 Neoplasm of unspecified behavior of breast I80.8 Phlebitis and thrombophlebitis of other sites N60.01 Solitary cyst of right breast N60.02 Solitary cyst of left breast N60.09 Solitary cyst of unspecified breast N60.11 Diffuse cystic mastopathy of right breast N60.12 Diffuse cystic mastopathy of left breast N60.19 Diffuse cystic mastopathy of unspecified breast N60.21 Fibroadenosis of right breast N60.22 Fibroadenosis of left breast N60.29 Fibroadenosis of unspecified breast N60.31 Fibrosclerosis of right breast N60.32 Fibrosclerosis of left breast N60.39 Fibrosclerosis of unspecified breast N60.41 Mammary duct ectasia of right breast N60.42 Mammary duct ectasia of left breast N60.49 Mammary duct ectasia of unspecified breast N60.81 Other benign mammary dysplasias of right breast N60.82 Other benign mammary dysplasias of left breast N60.89 Other benign mammary dysplasias of unspecified breast N60.91 Unspecified benign mammary dysplasia of right breast N60.92 Unspecified benign mammary dysplasia of left breast
5 N60.99 Unspecified benign mammary dysplasia of unspecified breast N61 Inflammatory disorders of breast N62 Hypertrophy of breast N64.0 Fissure and fistula of nipple N64.1 Fat necrosis of breast N64.2 Atrophy of breast N64.89 Other specified disorders of breast N64.3 Galactorrhea not associated with childbirth N64.4 Mastodynia N63 Unspecified lump in breast N64.51 Induration in breast N64.52 Nipple discharge N64.53 Retraction of nipple N64.59 Other signs and symptoms in breast N64.81 Ptosis of breast N64.82 Hypoplasia of breast N64.9 Disorder of breast, unspecified R92.8 Other abnormal and inconclusive findings on diagnostic imaging of breast R92.0 Mammographic microcalcification found on diagnostic imaging of breast R92.2 Inconclusive mammogram R92.1 Mammographic calcification found on diagnostic imaging of breast S21.001A Unspecified open wound of right breast, initial encounter S21.002A Unspecified open wound of left breast, initial encounter S21.009A Unspecified open wound of unspecified breast, initial encounter S21.011A Laceration without foreign body of right breast, initial encounter S21.012A Laceration without foreign body of left breast, initial encounter S21.019A Laceration without foreign body of unspecified breast, initial encounter S21.031A Puncture wound without foreign body of right breast, initial encounter S21.032A Puncture wound without foreign body of left breast, initial encounter S21.039A Puncture wound without foreign body of unspecified breast, initial encounter S21.051A Open bite of right breast, initial encounter S21.052A Open bite of left breast, initial encounter S21.059A Open bite of unspecified breast, initial encounter S28.211A Complete traumatic amputation of right breast, initial encounter S28.212A Complete traumatic amputation of left breast, initial encounter S28.219A Complete traumatic amputation of unspecified breast, initial encounter S28.221A Partial traumatic amputation of right breast, initial encounter
6 S28.222A S28.229A S21.021A S21.022A S21.029A S21.041A S21.042A S21.049A T85.41XA T85.42XA T85.43XA T85.44XA T85.49XA Partial traumatic amputation of left breast, initial encounter Partial traumatic amputation of unspecified breast, initial encounter Laceration with foreign body of right breast, initial encounter Laceration with foreign body of left breast, initial encounter Laceration with foreign body of unspecified breast, initial encounter Puncture wound with foreign body of right breast, initial encounter Puncture wound with foreign body of left breast, initial encounter Puncture wound with foreign body of unspecified breast, initial encounter Breakdown (mechanical) of breast prosthesis and implant, initial encounter Displacement of breast prosthesis and implant, initial encounter Leakage of breast prosthesis and implant, initial encounter Capsular contracture of breast implant, initial encounter Other mechanical complication of breast prosthesis and implant, initial encounter T85.79XA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter Z85.3 Personal history of malignant neoplasm of breast Z91.89 Other specified personal risk factors, NEC Z03.89 Encounter for observation for other suspected diseases and conditions ruled out
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