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Medicare Part B Coverage and Billing Guidance for Breast Ultrasound
Breast ultrasound uses sound waves to produce pictures of the inside of the breast and can show changes that are more difficult to see on a mammogram. Breast ultrasound is not routinely used for screening purposes and is used to help diagnose breast abnormalities detected during a physical examination or on mammography. To ensure Medicare coverage of breast ultrasounds, it’s helpful to understand coverage indications and limitations, billing and coding guidelines, documentation requirements, and regulatory guidelines.
Coverage Indications and Limitations
Local Coverage Determination (LCD) L33585, Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography outlines coverage indications and limitations for breast ultrasounds. According to LCD L33585, breast ultrasound may be indicated for the following conditions:
- Guidance for breast interventional procedures
- Assessment of implant related problems
- Radiation treatment planning
- Initial evaluation of palpable masses in women under 30
- In lactating and pregnant women
- Assessment of palpable abnormalities on physical exam
- Assessment to distinguish simple mastitis from abscess formation
- Assessment of any mass to determine whether it is suitable for percutaneous intervention (core biopsy, for instance)
- Assess stability of a sonographically visible mass that is mammographically invisible
- Nonpalpable masses, detected by mammography, to differentiate cysts from solid lesions
- Palpable masses, if needle aspiration is not performed
- Symptomatic, possible ruptured silicone breast prosthesis when an MRI is not possible
- Calcifications to determine if an invasive component exists that would be amenable to core biopsy when supported by additional clinical indications.
To be covered, the ultrasound must be diagnostic in nature and not for screening purposes. It is important to note that dense breast tissue alone does not constitute medical necessity. A breast ultrasound may be indicated if breast density interferes with the ability to diagnose abnormal findings on mammography. The significance of dense breast tissue should be explained to the beneficiary so that they can make informed decisions about their care.
A treating provider’s order is required for breast ultrasound. There are instances of ordering physicians ordering both a screening mammography and an ultrasound on the same day without awaiting mammography results. This may be considered a screening ultrasound and screening ultrasounds are not a covered service. Providers should communicate with the ordering physicians to ensure that the ultrasound is ordered and completed only as necessary following a mammography. Breast ultrasound should not be routinely used with diagnostic mammography; however, it may be necessary to further evaluate concerning or ambiguous findings detected upon mammography. There are some instances in which a breast ultrasound may be performed without having a diagnostic mammography first. An example of this circumstance is provided in LCD L33585.
In any case, if there is concern for or anticipation of noncoverage for the breast ultrasound, a detailed Advance Beneficiary Notice of Noncoverage (ABN) specific to the beneficiary should be issued. For complete instructions on issuing ABNs, visit the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.
Billing and Coding Guidance
Local Coverage Article (LCA) A52849, Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography provides comprehensive coding guidance that complements LCD L33585 and includes a list of diagnosis codes that support medical necessity. The following represents key information found within LCA A52849:
- Codes 76641 and 76642 are designated for unilateral breast ultrasound procedures.
- For bilateral procedures, a modifier 50 should be reported.
- An E/M service by the radiologist on the same or subsequent day as a breast ultrasound should not be separately reported.
The patient’s medical record must contain documentation that fully supports the medical necessity of the breast ultrasound according to LCD 33585. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
A clear, clinical indication for the breast ultrasound must be documented in the medical record, as well as in the referral order. The medical record must also include a formal written report describing all the views completed. The formal written report must include the reason for the test, a description of the test, the interpretation and results of the test, and the name of the physician to whom the report is being sent.
Regulatory Guidelines and References
- Title XVIII of the Social Security Act (SSA), Section 1833(e) and Section 1862(a)(1)(A)
- Code of Federal Regulations (CFR) Title 42, Sections 410.32 and 410.34, and Section 486
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 80.4.3, 80.4.4, and 80.6
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Section 90
- National Coverage Determination (NCD) 220.5: Ultrasound Diagnostic Procedures
- LCD L33585: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography
- LCA A52849: Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography