88161
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.49
Facility
$82.83
Non-Facility
$82.83
Documentation Required
- When billing, use appropriate supporting procedure and cytology codes as applicable (policy lists related CPT/HCPCS codes: 19030, 77053, 77054, 88112, 88161) and the applicable ICD-10 diagnosis codes (covered: C50.011-C50.929; N64.52).
- For breast ductal lavage to be considered medically necessary: documentation of non-lactational sporadic nipple discharge AND documentation that the yield of cellular material from a direct nipple aspirate is too low to permit adequate cytological analysis (policy language: "where the yield of cellular material from a direct nipple aspirate is too low to permit adequate cytological analysis").
- For fiberoptic ductoscopy to diagnose intra-ductal lesions: documentation of non-lactational sporadic nipple discharge accompanied by documented positive cytology (policy language: "non-lactational sporadic nipple discharge accompanied by documented positive cytology").
Key Coverage Criteria
- ICD-10: N64.52 Nipple discharge [non-lactational sporadic nipple discharge]
- Breast ductal lavage as an appropriate alternative to aspiration to diagnose members with non-lactational sporadic nipple discharge where the yield of cellular material from a direct nipple aspirate is too low to permit adequate cytological analysis.
- Fiberoptic ductoscopy combined with cytology testing for diagnosing intra-ductal lesions in women with non-lactational sporadic nipple discharge accompanied by documented positive cytology.
- Fiberoptic ductoscopy as a guide for resection of known breast intra-ductal cancer.
- ICD-10: C50.011 - C50.929 Malignant neoplasm of breast [covered for known breast intraductal cancer when fiberoptic ductoscopy is used as a guide for resection only]
- Preventive care services designated by the Affordable Care Act (ACA) and ACA-designated resources (USPSTF grade A or B recommendations; ACIP recommendations adopted by CDC Director; HRSA-supported comprehensive guidelines such as Bright Futures, Uniform Panel of Secretary's Advisory Committee on Heritable Disorders in Newborns and Children, HRSA Women's Preventive Services Guidelines).
2 Active Policies
CIGNA-A004 — Preventive Care Services - (A004)
AETNA-CPB-0517 — Breast Ductal Lavage and Fiberoptic Ductoscopy
Related Codes
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