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Hattiesburg Posted Tue 21st of November, 2017 11:59:19 AM
I just go the new updated National policy from Medicare on the mammogram policy and they have added the new N63.xx codes but they do not have any of the codes that end in zero, like N63.10, N63.20. What are we to do about lumps, masses that fall at the 12, 6, 2 or 9 o'clock positions? Those areas do not fall into a specific quadrant and would there for be coded to N63.10 or N63.20 depending on which breast it was but Medicare is not considering these codes.
SuperCoder Answered Wed 22nd of November, 2017 02:41:06 AM

According to the update from the CMS, N63.xx is the code series added newly, but until unless they do not mention that these codes are not covered under specific policy, you can bill by providing the medical necessity of the patient.

With an assumption, possibly mammogram policy might not be mentioning these codes (N63.10, N63.20) because of unspecified lump in unspecified quadrant of the breast.

Since, N63.xx is mentioned, then you can go ahead with your child codes do this series.


Check below the limitations and indications of coverage under mammogram policy of CMS:


Limitations of Coverage:

A diagnostic mammography is a covered service if it is ordered by a doctor of medicine or osteopathy.

Payment may not be made for a screening mammography performed on a woman under age 35. Payment may be made for only one screening mammography performed on a woman over age 34, but under age 40. For an asymptomatic woman over age 39, payment may be made for a screening mammography performed after at least 11 months have passed following the month in which the last screening mammography was performed.


Indications of Coverage:


A radiological mammogram is a covered diagnostic test under the following conditions:

  • A patient has distinct signs and symptoms for which a mammogram is indicated;
  • A patient has a history of breast cancer; or
  • A patient is asymptomatic but, on the basis of the patient’s history and other factors the physician considers significant, the physician's judgment is that a mammogram is appropriate.


Use of mammograms in routine screening of:

(A) asymptomatic women aged 50 and over, and

(B) asymptomatic women aged 40 or over whose mothers or sisters have had the disease, is considered medically appropriate, but would not be covered for Medicare purposes.

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