N64.9 — Disorder of breast, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Documentation supporting services must be available to Medicare upon request.
- The medical record must contain the ordering provider's assessment related to the patient's complaint, relevant medical history, and results of pertinent tests/procedures.
- All services ordered or rendered must be signed and dated; signed and dated office visit records or operative reports must be in the record.
- A clear clinical indication for diagnostic mammogram, breast sonogram, breast MRI, or ductogram must be documented in the medical record and in the referral/order.
Key Coverage Criteria
- 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.
- Medicare covers annual screening mammography for all women age >=40 and one baseline screening mammography for women age 35-39, using bilateral views.
- Diagnostic mammography is indicated for patients with signs or symptoms suggestive of breast malignancy (e.g., palpable mass, spontaneous nipple discharge, skin changes, unilateral breast pain, unilateral axillary lymphadenopathy).
- Diagnostic mammography is indicated for radiographic abnormalities detected on screening mammography.
- Diagnostic mammography is indicated when metastatic disease of undetermined etiology is present and the breast is suspected as the primary source, or for axillary lymphadenopathy of undetermined etiology.
6 Active Policies
CIGNA-0398 — Transvaginal Ultrasound, Non-Obstetrical - (0398)
AETNA-CPB-0105 — Magnetic Resonance Imaging (MRI) of the Breast
AETNA-CPB-0231 — Grenz Ray Therapy for Skin Disorders
AETNA-CPB-0517 — Breast Ductal Lavage and Fiberoptic Ductoscopy
A56448 — Billing and Coding: Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography
Related Codes
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