T85.43XA — Leakage of breast prosthesis and implant, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high 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.
17 Active Policies
L39051 — Cosmetic and Reconstructive Surgery
J05
A58774 — Billing and Coding: Cosmetic and Reconstructive Surgery
J05
A52849 — Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography
J06
L33585 — Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography
J06
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.