N64.0 — Fissure and fistula of nipple
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- The patient’s medical record must document medical necessity supporting the related LCD (L33585), including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- A clear clinical indication for the breast sonogram, breast MRI, or ductogram must be documented in both the medical record and the referral order.
- The medical record must include a formal written report describing all views completed, the reason for the test, a description of the test, interpretation and results, and the name of the physician to whom the report is being sent.
- For services requiring a referring/ordering physician, the name and UPIN or NPI of the referring/ordering physician must be reported on the claim; for breast sonography, breast MRI, and ductogram, the treating/ordering physician NPI is required on the claim (report in CMS-1500 item 17a or electronic equivalent).
Key Coverage Criteria
- Breast sonography (CPT 76641, 76642) is covered when the medical record documents medical necessity per the related LCD (L33585); if performed bilaterally, report modifier 50 with CPT 76641 or 76642.
- Breast MRI is covered only when billed with CPT code 77046, 77047, 77048, or 77049 and when medical necessity is documented per the related LCD (L33585).
- Mammary ductogram/galactogram is covered only when billed with CPT 77053 or 77054 and medical necessity is documented per the related LCD (L33585); use CPT 19030 for contrast injection when billed separately.
- For Part A facility billing, breast sonography should be billed using CPT 76641/76642; breast MRI may be billed using HCPCS C8903, C8905, C8906, C8908 or CPT 77046/77047; ductography should be billed using CPT 77053 or 77054.
- Diagnostic mammography, breast sonography (echography), breast MRI, and ductography are covered when a clear clinical indication for the test is documented in the medical record and in the referral/order.
- A diagnostic mammogram performed after an initial screening mammogram (conversion from screening to diagnostic) is allowable when the screening abnormality prompting additional views is documented in the record.
5 Active Policies
A52849 — Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography
J06
L33585 — Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography
J06
CIGNA-0398 — Transvaginal Ultrasound, Non-Obstetrical - (0398)
A56448 — Billing and Coding: Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.