December 31, 2015

Mammography Guidelines Revised in 2016 NCCI Policy Manual

In response to an American College of Radiology (ACR) appeal, the 2016 National Correct Coding Initiative (NCCI) Policy Manual has been revised to allow separate billing of a post-procedure mammogram performed after a stereotactic-guided breast procedure.

Revised wording, approved by the Centers for Medicare & Medicaid Services (CMS), appropriately reverts back to the 2014 guidelines (i.e., If a breast biopsy, needle localization wire, metallic localization clip or other breast procedure is performed with mammographic guidance (e.g., 19281, 19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.)

The current 2015 guidelines do not allow the reporting of a post-procedure mammogram when mammography or stereotactic guidance is used for a breast procedure. A post-procedure mammography code in conjunction with the stereotactic breast biopsy codes 19081 or 19082 for the same patient encounter cannot be billed for services provided January 1 – December 31, 2015. You will have to wait until January 1, 2016 to bill a post-procedure mammogram following a stereotactic-guided breast procedure.

In 2013, the ACR originally sent two letters of appeal and met with CMS and NCCI officials via teleconference to discuss this issue and to correct the wording. CMS agreed with the ACR that the only imaging included with a breast procedure was imaging performed on the same modality. Therefore, all mammograms were included in a mammo-guided procedure. After a two-year struggle, CMS started paying in 2014 for post-procedure mammograms when the procedure was performed with stereotactic, ultrasound or MR guidance.

However, the revised 2015 guidelines reverted back to the incorrect language, which did not allow payment for a post-procedure mammogram performed following a stereotactic-guided breast procedure.

The ACR again sent an appeal requesting that the NCCI manual dealing with breast biopsy be revised. The ACR based its argument on all the same reasons that it used to help overturn the 2013 guidelines i.e., stereotactic and mammographic guidance are different procedures. The radiologic guidance code includes all imaging required to perform the procedure on the same imaging modality (i.e., all stereotactic imaging for a stereotactic-guided procedure, all ultrasound imaging for an ultrasound-guided procedure and all MRI imaging for an MRI-guided procedure). A post-procedure mammogram performed on a separate piece of equipment to document exact location of the clip in relation to the biopsy bed, and to look for residual calcifications or ensure lesion biopsied and marked with clip corresponds to the lesion initially seen on mammography is not part of the image-guided procedure, but is performed after the procedure has been completed, and is separately reportable. For procedures performed under mammographic guidance, all of the mammographic imaging is included in the procedure and is not separately reported.

Unfortunately, there is no opportunity for specialty medical societies to review and comment on the NCCI Policy Manual changes before they are implemented. It is not until the manual is published that the ACR can become aware of the new guidelines. Though CMS may eventually agree with the appeal, the edits remain in effect until the next year when the policy manual is updated. The ACR again requested that we be given the opportunity to review and comment on any changes, but CMS maintains that decisions concerning the manual’s content are not announced until they are posted.