Smash 3 Myths to Upgrade Your Mammography Coding and Coverage Knowledge

Medicare mammography coding and coverage

Mammography is a common service, but radiology coders need to learn some not-so-common rules. Take your know-how to the next level by getting to the truth about these myths.

Myth 1: Mammography Is for Women Only

Medicare’s National Coverage Determination (NCD) for Mammograms states that “diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician’s interpretation of the results of the procedure” (emphasis added).

From a coverage standpoint, Medicare considers a screening mammogram to be “furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer” (emphasis added).

Verdict: The idea that mammograms are for women only is definitely a myth. But you need to be aware of payer’s coverage rules for different types of mammograms. As in the case of Medicare, screening mammograms are covered only for women.

Myth 2: Screening Mammography Requires an Order to be Covered

Orders are hugely important in radiology, but screening mammography has its own rules.

While Medicare covers diagnostic mammography ordered by a doctor of medicine or osteopathy, the Medicare Benefit Policy Manual (MBPM), chapter 15, section 280.3, states, “A doctor’s prescription or referral is not necessary for the procedure to be covered. Payment may be made for a screening mammography furnished to a woman at her direct request, and based on a woman’s age and statutory frequency parameter.”

For instance, Medicare covers one screening mammogram between a woman’s 35th and 40th birthdays. Over age 39, the rule for MACs is to “pay for a screening mammography performed after 11 full months have passed following the month in which the last screening mammography was performed.” To explain that last confusing requirement, the MBPM clarifies that if a patient has an exam in January, Medicare will pay for another screening mammogram the next January.

Verdict: Medicare doesn’t require documentation to include an order to cover screening mammography. But your patients may need some help keeping track of when they’re eligible for another screening mammogram.

Myth 3: There Is No Standard Definition of Screening Mammography

We’ve already covered that Medicare has separate definitions for diagnostic and screening in the mammography NCD. In that NCD, Medicare also states that a screening mammography “must be, at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast.”

But there are some areas where providers have more discretion. For instance, Medicare’s NCD states that mammography is a covered diagnostic test if a patient has a history of breast cancer. But the NCD doesn’t state that patients with a history of breast cancer can have only a diagnostic test. Experts advise that a patient’s attending physician may decide that a screening mammogram, rather than a diagnostic mammogram, is appropriate based on the patient’s history and current status.

Verdict: Medicare provides some specifics about what screening mammography is, but you need to be aware of the gray areas, too.

What About You?

What mammography coding scenarios have you encountered that raised questions for you?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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