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Periodically, the Medical Review Department will receive a request to consider payment of breast ultrasound (procedure code 76645) for the diagnosis of V76.12 (Screening mammogram), instead of a screening mammogram for Medicare beneficiaries who are unable to tolerate screening mammography due to reduced mental capacity.
Guidelines for screening mammography can be found in Pub. 100-2, Medicare Benefit Policy Manual, Chapter 15, §280.3. The guidelines include specific limitations which state that the screening mammography benefit specifically pertains to mammogram only, and does not include a provision to replace mammography with breast ultrasound, in the event a mammogram cannot be tolerated.
In addition to the national guidelines, the Breast Imaging: Mammography/Breast Echography (Sonography)/Breast MRI/Ductography local coverage determination (LCD), #RD001E04 (LCD Database ID #L3761) provides specific guidelines for annual screening mammography. Providers are instructed to bill code 76092 or G0202, and there is no provision to report the service as breast ultrasound instead of mammogram. Diagnosis code V76.12 is not an accepted payable diagnosis for breast ultrasound. Also, the LCD addresses the use of breast ultrasound and states, "breast ultrasound should not routinely be used along with diagnostic mammography" and "ultrasonography may be indicated in addition to diagnostic mammography for the evaluation of some ambiguous mammographic or palpable masses or focal asymmetric densities that may represent a mass."
Because both the national screening guidelines and the LCD are very specific and allow only mammography for the screening benefit, a breast ultrasound cannot replace a screening mammography. Accordingly, the Upstate Medicare Division (UMD) does not allow payment of breast ultrasound as a screening benefit for a beneficiary who is unable to tolerate screening mammography. Breast Ultrasound in Replacement of Screening Mammography
Guidelines for screening mammography can be found in Pub. 100-2, Medicare Benefit Policy Manual, Chapter 15, §280.3. The guidelines include specific limitations which state that the screening mammography benefit specifically pertains to mammogram only, and does not include a provision to replace mammography with breast ultrasound, in the event a mammogram cannot be tolerated.
In addition to the national guidelines, the Breast Imaging: Mammography/Breast Echography (Sonography)/Breast MRI/Ductography local coverage determination (LCD), #RD001E04 (LCD Database ID #L3761) provides specific guidelines for annual screening mammography. Providers are instructed to bill code 76092 or G0202, and there is no provision to report the service as breast ultrasound instead of mammogram. Diagnosis code V76.12 is not an accepted payable diagnosis for breast ultrasound. Also, the LCD addresses the use of breast ultrasound and states, "breast ultrasound should not routinely be used along with diagnostic mammography" and "ultrasonography may be indicated in addition to diagnostic mammography for the evaluation of some ambiguous mammographic or palpable masses or focal asymmetric densities that may represent a mass."
Because both the national screening guidelines and the LCD are very specific and allow only mammography for the screening benefit, a breast ultrasound cannot replace a screening mammography. Accordingly, the Upstate Medicare Division (UMD) does not allow payment of breast ultrasound as a screening benefit for a beneficiary who is unable to tolerate screening mammography. Breast Ultrasound in Replacement of Screening Mammography
