T85.79XS — Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, sequela
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.
- Occupational therapy is covered for patients with migraine (G43.xx) who require training to reduce pain during basic and instrumental activities of daily living, typically completed in 3–4 sessions.
- Electrical stimulation (attended CPT 97032 or unattended HCPCS G0283) may be covered as part of a therapy plan of care to improve function when the nerve supply to the muscle is intact and atrophy is due to non-neurological disuse (e.g., post-casting, splinting, soft-tissue scarring).
20 Active Policies
A58774 — Billing and Coding: Cosmetic and Reconstructive Surgery
J05
L39051 — Cosmetic and Reconstructive Surgery
J05
L33585 — Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography
J06
L34380 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
Related Codes
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