Procedure Code and description

76536 – Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation – Average fee amount – $110 – $120

76604 – Ultrasound, chest (includes mediastinum), real time with image documentation

76641 – Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete average fee amount – $100 – $120


76498 Unlisted magnetic resonance procedure (e.g., diagnostic, interventional)

76499 Unlisted diagnostic radiographic procedure

76641  Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete


76642  Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited

77058  Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral

77059 Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral

77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral

77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral

77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed



Coverage Indications, Limitations, and/or Medical Necessity

    Ultrasound of the head and neck will be considered medically reasonable and necessary when used for the following indications:

    · Evaluation of abnormalities in the tissues and/or organs of the head and neck (i.e., palpable masses)

    · Evaluation of abnormalities detected on other imaging examinations (i.e., areas of abnormal uptake seen on radioisotope thyroid examinations)

    · Personal or family history of thyroid malignancies

    · Evaluation of suspected regional nodal metastases in patients with a proven thyroid carcinoma

    · Follow-up of lesion/nodule (i.e., after medical suppression therapy)

    · Localization of thyroid/parathyroid glands or cervical lymph nodes for biopsy, ablation, or other interventional procedures

  Dysphagia/swallowing therapy is a medically prescribed treatment concerned with improving or restoring functions which have been impaired by illness or injury. Phases of swallowing addressed include oral, pharyngeal, and/or esophageal (upper one third) phases of swallowing.

    Dysphagia is a swallow disorder that may be due to various neurological, structural, and cognitive deficits. Dysphagia may be the result of head trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, and encephalopathies. While dysphagia can afflict any age group, it most often appears among the elderly.

    The diagnosis of dysphagia, or difficulties in swallowing, requires an extensive evaluation by the physician. Many difficulties can be identified and treated based on the findings of this examination alone. In some cases, more extensive evaluations are required using a variety of studies such as echography and modified barium swallow studies and an evaluation by a swallowing therapist.

    The treatment of dysphagia/swallowing difficulties may include simple recommendations for such things as intake consistency or positioning, or may require a therapeutic regime targeted at the attainment of functional improvement.

    Patients who are motivated, moderately alert, and have some degree of deglutition and swallowing functions are appropriate candidates for dysphagia therapy. Elements of the therapy program can include thermal stimulation to heighten the sensitivity of the swallowing reflex, exercises to improve oral-motor control, training in laryngeal adduction and compensatory swallowing techniques, and positioning and dietary modifications. Design all programs to ensure swallowing safety of the patient during oral feedings and maintain adequate nutrition.

    Speech-language pathology services are covered under Medicare for the treatment of dysphagia, regardless of the presence of a communication disability.

    Dysphagia/swallowing therapy is medically necessary when the following conditions are met:

    · The patient must be under the care of a physician. The attending physician may be the patient’s private physician or a physician associated with an institution. Collaboration between the physician and the speech language pathologist or other dysphagia therapist is necessary to establish the medical necessity for the dysphagia evaluation and/or treatment.

    · The therapy must be furnished under the written plan of treatment, with measurable goals and time frames established by the physician or therapist caring for the patient. The services must be of such a level of complexity and sophistication that they can only be performed by a qualified dysphagia therapist.

    · The physician must establish a preliminary diagnosis addressing the symptoms associated with the dysphagia. This preliminary diagnosis should address the treatability of the patient in terms of the patient’s:

        level of alertness

        ability to cooperate

        ability to retain new learning

        cognitive status

        medical stability

        psychological stability

    · There must be a recent significant change in swallowing function for a dysphagia evaluation to be medically necessary. One or more of the following conditions must be present:

        History of aspiration problems or definite risk of aspiration.

        Impaired salivary gland performance and/or presence of local structural lesions in the pharynx in marked oropharyngeal swallowing difficulties.

        Dyscoordination, sensation loss, postural difficulties, or other neuromotor disturbances affecting oropharyngeal abilities necessary to close the buccal cavity and/or bite, chew, suck, shape, and squeeze the food bolus into the upper esophagus, while protecting the airway.

        Post surgical reaction.

        Significant weight loss directly related to reduced oral intake as a consequence of dysphagia.

        Existence of other conditions such as: presence of tracheotomy tube, nasogastric feeding tube, endotracheal tube, or ventilator reduced or inadequate laryngeal elevation, labial closure, velopharyngeal closure, laryngeal closure, or pharyngeal peristalsis and cricopharyngeal disjunction.

    Videofluroscopy or other visual instrumental assessments should be conducted when oral or pharyngeal disorders are suspected. Documentation must establish that an exact diagnosis cannot be substantiated through oral exam and that there is a question as to whether aspiration is occurring. The videofluoroscopic assessment is usually conducted and interpreted by a radiologist with the assistance and input from the physician and/or individual disciplines. The assessment and final analysis and interpretation should include a definitive diagnosis, identification of the swallowing phase(s) affected, and a recommended treatment plan.

Revenue Codes


    Code Description

    0320 Radiology – Diagnostic – General Classification
    0321 Radiology – Diagnostic – Angiocardiography
    0322 Radiology – Diagnostic – Arthrography
    0323 Radiology – Diagnostic – Arteriography
    0324 Radiology – Diagnostic – Chest X-Ray
    0329 Radiology – Diagnostic – Other Radiology – Diagnostic

AACE appreciates the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS)  proposed rule and revisions to Medicare Part B payment policies under the Medicare Physician Fee Schedule (MPFS) for Calendar Year 2016, published in the Federal Register on July 15, 2015.

Our comments pertain to the following issues:

1. Identification of Procedure™ Code 76536 as a Potentially Misvalued Code

2. Improved Payment for the Professional Work of Care Management Services

3. Establishing Separate Payment for Collaborative Care

4. CCM and TCM Services

5. Target for Relative Value Adjustments for Misvalued Services

6. Phase-In for Significant RVU Reductions

7. Clinical Improvement Activities under MIPS

8. Physician Compare




1. Identification of Procedure Code 76536 as a Potentially Misvalued Code

Proposed Rule: CMS has included Procedure™ code 76536, ultrasound exam of head and neck, in a list of potentially misvalued codes identified through the high expenditure by specialty screen.

Procedure™ code 76536 was surveyed in April 2009 and proposed interim relative value units (RVUs) were included in the Medicare Physician Fee Schedule final rule for CY2010. CMS published final RVUs for Procedure™ code 76536 in the 2011 Medicare Physician Fee Schedule final rule. AACE maintains that these actions constitute review of Procedure™ code 76536 within the last five years and therefore Procedure™ code 76536 does not fit the criteria for the misvalued code list and should be removed.

Payment Information

The following chart provides payment information that is based on the national unadjusted Medicare physician fee schedule for the ultrasound services discussed in this guide. Payment will vary by geographic region. Use the “Professional Payment” column to estimate reimbursement to the physician for services provided in facility settings.

Ambulatory Payment Classification (APC) codes and payments are used by Medicare to reimburse facilities under the Hospital Outpatient Prospective Payment System (OPPS). Payment is based on the national unadjusted OPPS amounts for facilities. The actual payment will vary by location.

Procedure Code       Procedure Code Descriptor   Global Payment   Professional Payment   Technical Payment   APC Code   APC Payment 



76536  Ultrasound, soft tissues of head and neck (e.g. thyroid, parathyroid, parotid), real time with image documentation

$123.59

$28.66

$94.93

0266

$134.57


Neck masses that are located on the anterior neck should have ultrasound (Procedure ®76536) performed as the initial imaging study.

For possible neck masses or fullness of the neck that is not well described on physical examination, ultrasound (Procedure ®76536) or ENT evaluation can be helpful in making decisions regarding the need for advanced imaging.

Ultrasound (Procedure ®76536) and nuclear medicine thyroid scan are the preferred initial imaging studies for suspected thyroid masses. If ultrasound shows a dominant mass, fine needle aspiration (FNA) should be the next diagnostic study.

Benign thyroid nodules should have a follow-up ultrasound (Procedure ®76536) 6 to 18 months after the initial FNA.

* If nodule size is stable, follow-up ultrasound exam (Procedure ®76536) can be performed every 3 to 5 years.

Incidental thyroid nodules found on imaging (ultrasound, CT, or MRI) can be followed by ultrasound (Procedure ®76536). FNA is indicated if there is concern for malignancy.

 Patients with a suspected substernal goiter (i.e. a major portion of the goiter lies within the mediastinum) should have a neck ultrasound (Procedure ®76536) or radionuclide study first to confirm extension of the thyroid to the sternum.

Reimbursement Rate Changes and Updates for Radiology Procedure Codes 76641 and 76642

Note: This article applies to claims submitted to TMHP for processing. For claims processed by a Medicaid managed care organization (MCO), providers must refer to the MCO for information about benefits, limitations, prior authorization, and reimbursement.

Effective June 12, 2015, for dates of services on or after January 1, 2015, the following reimbursement rate changes and updates for radiology procedure codes 76641 and 76642 were approved at the May 14, 2015, public rate hearing:

TOS* Procedure Code Age Range Non-Facility (N)/Facility (F) Medicaid RVU Effective 1/1/2015 Medicaid Conversion Factor Effective 1/1/2015 Medicaid Fee Effective 1/1/2015

4 76641 0-20 N/F 3.06 $28.0672 $85.89
4 76641 21-999 N/F 3.06 $26.7305 $81.80

Oxford has engaged eviCore Healthcare to perform initial reviews of requests for pre-certification and medical necessity reviews for CPT/HCPCS codes 0159T, 76377, 76499, 77058, 77059 and S8080 (Oxford continues to be responsible for decisions to limit or deny coverage and for appeals). 2Precertification is not required through eviCore Healthcare or Oxford for CPT/HCPCS codes 76641, 76642, 77051, 77052, 77055-77057, G0202, G0204, G0206 or G0279. 3Precertification is required for services covered under the Member’s General Benefits package when performed in the office of a participating provider. For Commercial plans, precertification is not required, but is encouraged for out-ofnetwork services performed in the office that are covered under the Member’s General Benefits package. If precertification is not obtained, Oxford may review for medical necessity after the service is rendered.

76641 – Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete.

For a bilateral breast ultrasound, a modifier 50 should be added to either 76641 or 76642 to indicate a bilateral procedure. The 2015 Medicare Physician Fee Schedule assigns a “1” bilateral indicator to both CPT codes 76641 and 76642 which means that Medicare will allow 150 percent of the standard reimbursement rate. There should not be two CPT codes billed if a bilateral ultrasound exam is needed.

BENEFIT CONSIDERATIONS FOR oxford 

Coverage must be provided for an ultrasound evaluation, a magnetic resonance imaging (MRI) scan, or other additional testing of an entire breast or breasts, after a baseline mammogram exam if the:

** Mammogram demonstrates extremely dense breast tissue,

** Mammogram is abnormal within any degree of breast density including:

o Not dense

o Moderately dense

o Heterogeneously dense or

o Extremely dense breast tissue

** Patient has additional risk factors for breast cancer including, but not limited to:

o Family history of breast cancer

o Prior personal history of breast cancer

o Positive genetic testing

o Extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the

American College of Radiology or

o Other indications as determined the patient’s health care provider

Coverage of the above services (ultrasound, MRI, etc.) will be provided under a Member’s:

** Preventive benefit when it the service is performed as a result of any of the above indications.

** General benefit package when the service is performed as a result of any indication other than those listed above (i.e., Lump or mass in breast, etc.). Diagnostic services are may be subject cost share (i.e., co-payment and/or co-insurance). Please refer to the Member specific benefit plan document for details regarding benefit coverage.

For additional information on baseline mammogram services, refer to the policy titled Preventive Care Services.

COVERAGE RATIONALE

Important Note: Oxford has engaged eviCore healthcare to perform initial reviews of requests for precertification and medical necessity reviews for CPT/HCPCS codes 0159T, 76377, 76499, 77058, 77059, and S8080. (Oxford continues to be responsible for decisions to limit or deny coverage and for appeals.)

To pre-certify a radiology procedure, please call eviCore healthcare at 1-877-PRE-AUTH (1-877-773-2884) or log onto the eviCare healthcare web page at www.evicore.com.

eviCore has established an infrastructure to support the review, development, and implementation of comprehensive outpatient imaging criteria. The radiology evidence-based guidelines and management criteria are available on the eviCore healthcare website: www.evicore.com.

Please refer to the policy titled Radiology Procedures Requiring Precertification for eviCore healthcare Arrangement for applicable CPT/HCPCS codes and additional requirements, if applicable.

Breast Imaging as an Adjunct to Mammography Digital mammography is proven and medically necessary for patients with dense breast tissue.


Breast Magnetic Resonance Imaging (MRI)

Breast magnetic resonance imaging (MRI) is proven and medically necessary for patients at high risk for breast cancer as defined as having any of the following:

** Personal history of atypical breast histologies

** Family history or genetic predisposition for breast cancer

** Prior therapeutic thoracic radiation therapy

** Dense breast tissue with any one of the following risk factors:

o Lifetime risk of breast cancer of =20%, according to risk assessment tools based on family history

o Personal history of BRCA1 or BRCA 2 gene mutations

o First-degree relative with a BRCA 1 or BRCA 2 gene mutation but no having had genetic testing themselves

o Prior therapeutic thoracic radiation therapy between ages of 10-30

o Personal history of Li Fraumeni Syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome or a first-degree relative with one of these syndromes.

Breast magnetic resonance imaging (MRI) is unproven and not medically necessary for patients with dense breast tissue not accompanied by defined risk factors as described above.

Magnetic Resonance Elastography of the Breast Magnetic resonance elastography (MRE) is unproven and not medically necessary for breast cancer screening or diagnosis.

There is insufficient evidence to conclude that MRE of the breast is effective for the screening or diagnosis of breast cancer. While data from small feasibility studies indicate that MRE may have some ability to discriminate between cancerous tissue and normal breast tissue or benign lesions based on tissue stiffness, there was overlap in values, and the diagnostic accuracy of MRE for detection of breast cancer remains to be determined. There are no definitive patient selection criteria for MRE for breast cancer detection.

Breast Specific Gamma Imaging (Scintimammography)

Scintimammography is unproven and not medically necessary for breast cancer screening or diagnosis. There is insufficient evidence that this diagnostic modality can differentiate benign from malignant breast lesions. Based on the evidence, the role of scintimammography remains unclear since this technology has not been shown to be accurate enough to screen for breast cancer or allow a confident decision to defer biopsy.




Electrical Impedance Scanning (EIS)

Electrical impedance scanning (EIS) is unproven and not medically necessary for the detection of breast cancer.

There is insufficient evidence that EIS is effective in detecting malignant breast tissue. Evaluation of sensitivity and negative predictive value for EIS is inconsistent. Well-designed studies are needed to determine whether or not EIS is effective as an adjunct to mammography or provides a positive clinical benefit.


Computer Aided Detection for MRI of the Breast

Computer-aided detection (CAD) is unproven and not medically necessary as an aid for radiologists to interpret contrast-enhanced magnetic resonance imaging (MRI) of the breast. Clinical evidence has not yet demonstrated that CAD improves patient outcomes or reduces breast cancer mortality  when added to contrast-enhanced MRI. There is insufficient evidence to assess whether the use of CAD systems would maintain or increase the sensitivity, specificity, and recall rates of MRI of the breast. Prospective, well-designed and executed studies are needed to determine whether or not the use of CAD provides a positive clinical benefit.


Breast Ultrasound

Breast ultrasound is unproven and not medically necessary for routine breast cancer screening including patients with dense breast tissue.

Clinical evidence has not yet demonstrated that routine use of ultrasonography as an adjunct to screening mammography reduces the mortality rate from breast cancer.

Breast ultrasound is proven and medically necessary as an aid for radiologists to localize breast lesions and in guiding placement of instruments for cyst aspiration and percutaneous breast biopsies.

Computer-Aided Detection for Ultrasound Computer-aided detection (CAD) is unproven and not medically necessary as an aid for radiologists to detect breast cancer during ultrasound.

Clinical evidence has not yet demonstrated that CAD improves patient outcomes or reduces breast cancer mortality when added to ultrasonography. Future research should include better-designed studies, including prospective studies and randomized controlled trials evaluating this technology in large numbers of screening ultrasounds. Computer-Aided Tactile Breast Imaging Computer-aided tactile breast imaging is unproven and not medically necessary. Clinical evidence is insufficient to determine whether tactile breast imaging improves outcomes for the screening or diagnosis of breast cancer. Future research should include better-designed studies, including comparative, prospective and randomized controlled trials evaluating this  technology.

• For characterization of a breast nodule the recommended CPT code is 76645 (Breast ultrasound).

• For performing code 10022. A cyst drainage may be reported using 19000.

• For percutaneous needle core biopsy using imaging guidance use CPT code 19102.

• Ultrasound guidance of all percutaneous procedures described above should be reported separately. The recommended code is 76942.

• If performing a diagnostic breast ultrasound evaluation and an ultrasound guided needle procedure during the same patient encounter all three codes may be billed: the diagnostic ultrasound (76645), the ultrasound guidance (76942) and the biopsy (19102). Medicare CCI edits do not, at present, bundle the breast ultrasound and the ultrasound guidance of the biopsy, but some private payers may.

Automated Breast Ultrasound

Automated breast ultrasound is unproven and not medically necessary.

Clinical evidence is insufficient to determine whether automated breast ultrasound improves the detection rate of breast cancer compared to screening mammography. Future research should include better-designed studies, including prospective studies and randomized controlled trials evaluating this technology.

Refer to the eviCore healthcare Evidence Based Imaging Guidelines – Oxford for:

** Magnetic resonance imaging (MRI) of the breast

** 3D rendering of computed tomography, magnetic resonance imaging or other tomographic modalities





Chest Ultrasound Coding Notes

* Chest ultrasound: CPT®76604
* Breast ultrasound
o CPT®76641: unilateral, complete
o CPT®76642: unilateral, limited
o CPT®76641 and CPT®76642 should be reported only once per breast, per imaging session
* Axillary ultrasound: CPT®76882 (unilateral); if bilateral can be reported as CPT®76882 x 2

 Breast Ultrasound

* Routine performance of breast ultrasound as stand-alone screening or with screening mammography is inappropriate.
o Do NOT use breast ultrasound to screen general population as either a stand-alone study or a combined study with screening mammography.
* Breast ultrasound (CPT 76641: unilateral, complete OR CPT 76642: unilateral, limited) can be used to further evaluate abnormalities found on mammogram, especially in differentiating cysts from solid lesions.
o Bilateral should be coded CPT 76641 x 2 OR CPT 76642 x 2
* Palpable breast masses should be evaluated with mammography and breast ultrasound, in any order, regardless of age. Ultrasound can enhance biopsy.
* Axilla ultrasound (CPT®76882)
o For women with clinically suspicious lymph nodes, preoperative axillary ultrasound with a FNA or biopsy can help identify individuals who have positive nodes.
o Bilateral should be coded CPT®76882 x 2

Breast MRI Indications

* Low risk, probably benign (BI-RADS™ 3) lesions
o Repeat the original type study (mammogram, US or MRI) in 6 months, thereafter, screening or surveillance does not require MRI
* Suspicious (BI-RADS™ 4 or 5) lesion on mammogram and/or ultrasound
o Bilateral total breast ultrasound (CPT®76641: unilateral, complete), and bilateral axillary ultrasound (CPT®76882) are recommended for individuals who have BI-RADSTM 4 or 5 abnormalities. If additional suspicious breast lesions or more extensive malignant breast disease is detected by ultrasound, the extent of disease can be mapped with ultrasound-guided biopsies (CPT®76942).
o A lesion categorized as have BI-RADSTM 4 or 5 should be biopsied.
o A palpable lesion should be considered for biopsy.

Nipple Discharge/Galactorrhea

* Mammogram should be obtained and ultrasound (CPT®76641: unilateral, complete or CPT®76642: unilateral, limited) as initial imaging:
o If mammogram and ultrasound are negative, a ductal excision is indicated. A ductogram may be useful to exclude multiple lesions and to localize lesions before surgery.
o Ductal excision is indicated even if the ductogram is negative.
o An MRI may be considered if a ductogram is technically limited
o For a Birads 4 or 5 based on mammogram and/or ultrasound, biopsy is indicated

Breast Pain (Mystodynia)

* Mammogram and ultrasound are the initial imaging for breast pain
* Advanced imaging is NOT routinely indicated in individuals with breast pain and negative evaluation (evaluation includes individual history and physical exam, pregnancy test, mammogram and ultrasound (CPT®76641: unilateral, complete or CPT®76642: unilateral, limited).

o If evaluation is not negative, see CH-25.5 Breast MRI Indications

Axillary Lymphadenopathy

There is no evidence-based support for advanced imaging of clinically evidenced axillary lymph adenopathy without biopsy.2, 3 Most axillary adenopathy is infectious in primary care settings. Metastatic axillary involvement from a lung or chest primary is highly unusual (CT Chest not often warranted).

* Localized axillary lymphadenopathy should prompt:
o Search for adjacent hand or arm injury or infection, and
o 3-4 week observation if benign clinical picture, and
o Excisional biopsy of most abnormal lymph node if condition persists or malignancy suspected
o No advanced imaging indicated
* Generalized axillary lymphadenopathy should prompt:
o Diagnostic work-up, including serological tests, for systemic diseases and
o Excisional biopsy of most abnormal lymph node if uncertainty persists
o See: ONC-27~Lymphomas in the Oncology Imaging Guidelines
* Occult Primary Cancer in axillary lymph node(s)

o Breast MRI (CPT®77059) can be performed if breast cancer is suspected and if physical exam and mammography are negative. Otherwise, imaging of other possible primary sites are led by symptomatology, and risk factors


Breast MRI

* Breast MRI is usually bilateral (CPT®77059) or can be unilateral (CPT®77058) in some after mastectomy, per physician request.

* MRI guided breast biopsy (CPT®19085) includes the imaging component. Additional lesions should be billed using CPT®19086.

* MRI Breast can be repeated at least 6 months after an MRI directed breast biopsy to document successful lesion sampling if histology is benign and nonspecific, equivocal or uncertain.

Breast MRI – Practice Notes

Although breast MRI has superior sensitivity in identifying new unknown malignancies, it carries a significant false positive risk when compared to mammogram and ultrasound. Incidental lesions are seen on 15% of breast MRI’s and increase with younger age The percentage of incidental lesions that turn out to be malignant varies from 3% to 20% depending on the individual population. Cancer is identified by breast MRI in only 0.7% of those with “inconclusive mammographic lesions

Breast Reconstruction

* CTA or MRA of the body part from which the free tissue transfer flap is being taken, can be performed for breast reconstruction preoperative planning.2,3
o For example, CTA (CPT®74175 and CPT®72191) or MRA (CPT®74185 and CPT®72198) of the abdomen and pelvis for Deep Inferior Epigastric Perforators (DIEP) flap
* There is currently insufficient evidence-based data to support the need for routine advanced imaging for TRAM flaps or other flaps performed on a vascular pedicle


 CAD for Breast MRI

* The use of CAD with breast MRI is currently considered investigational, experimental, and/or unproven.
o 3D rendering codes (CPT®76376 or CPT®76377) should not be used in conjunction with code 0159T


Breast MRI is NOT Indicated

* Breast MRI should not be used to determine biopsy recommendations for suspicious or indeterminate lesion(s) that can be readily biopsied, either using imaging guidance or physical exam, such as palpable masses and microcalcifications.

* MRI should not be used for routine surveillance in individuals with history of breast cancer, unless there are physical exam, imaging findings, recurrent, or residual disease at the mastectomy site

Breast MRI Indications

* Breast MRI is indicated for breast augmentation, breast implants (saline or silicone), breast reconstruction, free injection, and capsular contracture to:
o Evaluate or confirm breast implant rupture when mammography or ultrasound is uninterpretable6
* If leakage is detected on MRI or any other modality, the implant(s) should be removed and no further surveillance MRI of the affected breast(s) is indicated.
* Surveillance for silent/asymptomatic rupture of silicone implants is considered investigational.
* Cigna does not cover surveillance MRI for breast implants if they were placed as part of purely cosmetic surgery.
* Annual breast MRI is indicated for high risk histologies:
o Atypical ductal hyperplasia (AD); Atypical lobular hyperplasia (ALH); Lobular carcinoma in situ (LCIS)
* Equivocal or Occult Findings
o Radiologist Report Recommendation for Breast MRI and one of the following:
* Inconclusive or conflicting findings on mammography or ultrasound of a lesion that is not a palpable mass
o A probably benign lesion on MRI (MRI BI-RADSTM 3) should undergo repeat MRI in 6 months.

* State Specific Breast Density Laws, after screening mammography and report identifies (BIRADS 1-3):

o New Jersey*

* Extremely dense breasts; or
* Any density with an abnormal mammogram; or
* The individual has additional risk factors for breast cancer
* The bill provides that the additional risk factors include, but are not limited to, family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue, or other indications** as determined by the individual’s health care provider.

* If multiple additional studies are recommended, there should be a logical progression of diagnostic procedures. For example, if additional mammographic images, digital breast tomosynthesis (DBT), and/or ultrasound as well as MRI are recommended, the results of the additional mammographic images, DBT and/or ultrasound studies should be obtained before an MRI is performed.

**If the additional risk factors do not correspond to one of those traditionally associated with high risk for breast cancer, the request should be evaluated by a medical director for validity.
* Newly Diagnosed Breast Cancer4
* Newly Diagnosed Paget’s Disease5 (thereafter treat as DCIS according to these guidelines)
* Annual breast MRI should begin at age 25 for individuals considered high risk:

CHEST IMAGING GUIDELINES

High Risk Indications

For 1 through 3, begin MRI screening at age 25
1. BRCA 1 or BRCA 2 mutation
2. Presence of Cowden, Bannayan-Riley-Ruvalcaba7

Genetic factors also associated with > 20% risk of breast cancer include ATM, CDH, CHEK2, PALB2, PTEN, STK11

For 3 through 9 above, MRI screening begins at age 40, or 10 years before the age of relative when he/she was first diagnosed with breast cancer, whichever is earlier
3. First degree relative (parent, sibling, child) with BRCA 1 or BRCA 2, even if an individual has not been tested for BRCA mutation
4. Two or more first degree relatives with breast or ovarian cancer
5. One first degree relative with breast cancer or ovarian cancer that was diagnosed < age 50
6. One first degree relative with bilateral breast cancer, or both breast and ovarian cancer
7. A first or second degree male relative (father, brother, uncle) diagnosed with breast cancer
8. Clinical lifetime risk estimated at greater than or equal to 20% using clinical risk estimator such as the Gail, Claus, Tyrer-Cuzick or BRCAPRO models
9. Ashkenazi Jewish women from families with onset of breast cancer before age 40

Additional Risks:
10. Women with history of radiation to the chest between ages 10 and 30; breast screening should start 8 to 10 years post-therapy, or at age 25, whichever comes first.
11 Li-Fraumeni Syndrome (TP53 mutation) should start annual breast screening MRI starting at age
20, or at the age of the earliest diagnosed breast cancer in the family, if below age 20 years of age

Billing Guideliens

• For characterization or identification of a thyroid nodule use CPT code 76536 – Ultrasound of soft tissues of head and neck.
• For percutaneous needle core biopsy of the thyroid, use code 60100. Image-guided, line needle aspirations may be billed using code 10022.
• For ultrasound guidance of a thyroid biopsy or cyst aspiration use CPT code 76942 – Ultrasonic guidance of needle placement. Report 76942 in addition to the code for the underlying procedure (e.g., 60100, 10022.)

Please review the National Correct Coding Initiative which also provides the following on multiple procedures:

• “CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.”
In addition per NCCI:
• “Ultrasound guidance and diagnostic ultrasound (echography) procedures may be reported separately only if each service is distinct and separate. If a diagnostic ultrasound study identifies a previously unknown abnormality that requires a therapeutic procedure with ultrasound guidance at the same patient encounter, both the diagnostic ultrasound and ultrasound guidance procedure codes may be reported separately. However, a previously unknown abnormality identified during ultrasound guidance for a procedure should not be reported separately as a diagnostic ultrasound procedure.”

76536 – Ultrasound, soft tissues of head and neck (e.g. thyroid, parathyroid, parotid), real time with image documentation

76942 – Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation.


Diagnostic Ultrasound with Ultrasound (US) Guidance Procedures

Limited Diagnostic Ultrasound Procedures reported with Ultrasound Guidance Procedures

* When a “limited” diagnostic ultrasound (i.e., CPT® 76705) and an ultrasonic guidance procedure (i.e., CPT® 76942) are reported on the same date, it is assumed by our claims system that both were performed during the same session in the same anatomic area. Based on CPT® guidelines, an US guidance procedure includes imaging protocols that are comparable to the limited diagnostic US. Therefore, when  these two procedures are reported together on the same date, the limited US is considered mutually exclusive to the US guidance. Mutually exclusive services are not eligible for separate reimbursement. The procedure with the higher RVU value is eligible for reimbursement.

Diagnostic Ultrasound Procedures reported with Ultrasound Guidance Procedures 

*  When an US guidance procedure (i.e., CPT® 76942) and an US procedure (i.e., CPT® 76536) are reported on the same date, it is assumed by our claims system that both were performed during the same session in the same anatomic area. Based on CPT® guidelines an US guidance procedure includes imaging protocols that are comparable to the US procedure. Therefore,when these two procedures are reported together on the same date, the US procedure is considered mutually exclusive to the US guidance. Mutually exclusive services are not eligible for separate reimbursement. The procedure with the higher RVU value is eligible
for reimbursement.

Ultrasound Guidance Procedures reported with Ultrasound Guidance Procedures

* When multiple US guidance procedures (i.e., CPT® 76930 and CPT® 76942) are reported on the same date, it is assumed by our claims system that both were performed during the same session in the same anatomic area and for similar clinical indications. When these procedures are reported together on the same date, the code with the lower RVU value will be considered mutually exclusive to the code with the higher RVU value. Mutually exclusive services are not eligible for separate reimbursement. The procedure with the higher RVU value is eligible for reimbursement. In each of these scenarios there may be particular clinical circumstances in which the procedures are performed on separate anatomic sites, and/or there may be distinct clinical indications for each study. In these circumstances, it will be necessary to append the appropriate modifier(s) to the code(s) to indicate such. Documentation in the medical record must support the reason for multiple reporting of these procedures

ICD CODE for Procedure 76536


C47.0 Malignant neoplasm of peripheral nerves of head, face and neck
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
C73 Malignant neoplasm of thyroid gland
C74.00 Malignant neoplasm of cortex of unspecified adrenal gland
C74.01 Malignant neoplasm of cortex of right adrenal gland
C74.02 Malignant neoplasm of cortex of left adrenal gland
C74.10 Malignant neoplasm of medulla of unspecified adrenal gland
C74.11 Malignant neoplasm of medulla of right adrenal gland
C74.12 Malignant neoplasm of medulla of left adrenal gland
C74.90 Malignant neoplasm of unspecified part of unspecified adrenal gland
C74.91 Malignant neoplasm of unspecified part of right adrenal gland
C74.92 Malignant neoplasm of unspecified part of left adrenal gland
C75.0 Malignant neoplasm of parathyroid gland
C75.4 Malignant neoplasm of carotid body
C76.0 Malignant neoplasm of head, face and neck
C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
C83.11 Mantle cell lymphoma, lymph nodes of head, face, and neck
C83.31 Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
C83.51 Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck
C83.81 Other non-follicular lymphoma, lymph nodes of head, face, and neck
C84.41 Peripheral T-cell lymphoma, not classified, lymph nodes of head, face, and neck
C84.61 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck
C84.71 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck
C85.21 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face, and neck
D09.3 Carcinoma in situ of thyroid and other endocrine glands
D09.8 Carcinoma in situ of other specified sites
D21.0 Benign neoplasm of connective and other soft tissue of head, face and neck
D34 Benign neoplasm of thyroid gland
D35.1 Benign neoplasm of parathyroid gland
D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
E01.0 Iodine-deficiency related diffuse (endemic) goiter
E01.1 Iodine-deficiency related multinodular (endemic) goiter
E01.2 Iodine-deficiency related (endemic) goiter, unspecified
E03.4 Atrophy of thyroid (acquired)
E04.0 Nontoxic diffuse goiter
E04.1 Nontoxic single thyroid nodule
E04.2 Nontoxic multinodular goiter
E04.8 Other specified nontoxic goiter
E04.9 Nontoxic goiter, unspecified
E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm
E05.10 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm
E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm
E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm
E05.21 Thyrotoxicosis with toxic multinodular goiter with thyrotoxic crisis or storm
E05.30 Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm
E05.31 Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm
E05.40 Thyrotoxicosis factitia without thyrotoxic crisis or storm
E05.41 Thyrotoxicosis factitia with thyrotoxic crisis or storm
E05.80 Other thyrotoxicosis without thyrotoxic crisis or storm
E05.81 Other thyrotoxicosis with thyrotoxic crisis or storm
E05.90 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm
E05.91 Thyrotoxicosis, unspecified with thyrotoxic crisis or storm
E06.0 Acute thyroiditis
E06.1 Subacute thyroiditis
E06.9 Thyroiditis, unspecified
E07.0 Hypersecretion of calcitonin
E07.1 Dyshormogenetic goiter
E07.89 Other specified disorders of thyroid
E07.9 Disorder of thyroid, unspecified
E21.4 Other specified disorders of parathyroid gland
E35 Disorders of endocrine glands in diseases classified elsewhere
K12.2 Cellulitis and abscess of mouth
L02.01 Cutaneous abscess of face
L02.11 Cutaneous abscess of neck
L03.211 Cellulitis of face
L03.212 Acute lymphangitis of face
L03.221 Cellulitis of neck
L03.222 Acute lymphangitis of neck
Q89.2 Congenital malformations of other endocrine glands
R22.0 Localized swelling, mass and lump, head
R22.1 Localized swelling, mass and lump, neck
R59.0 Localized enlarged lymph nodes
R59.1 Generalized enlarged lymph nodes
R59.9 Enlarged lymph nodes, unspecified
R90.0 Intracranial space-occupying lesion found on diagnostic imaging of central nervous system
R94.6 Abnormal results of thyroid function studies
Z85.850 Personal history of malignant neoplasm of thyroid
Z92.3 Personal history of irradiation

CHEST IMAGING GUIDELINES

High Risk Indications
For 1 through 3, begin MRI screening at age 25
1. BRCA 1 or BRCA 2 mutation
2. Presence of Cowden, Bannayan-Riley-Ruvalcaba7

Genetic factors also associated with > 20% risk of breast cancer include ATM, CDH, CHEK2, PALB2, PTEN, STK11

For 3 through 9 above, MRI screening begins at age 40, or 10 years before the age of relative when he/she was first diagnosed with breast cancer, whichever is earlier
3. First degree relative (parent, sibling, child) with BRCA 1 or BRCA 2, even if an individual has not been tested for BRCA mutation
4. Two or more first degree relatives with breast or ovarian cancer
5. One first degree relative with breast cancer or ovarian cancer that was diagnosed < age 50
6. One first degree relative with bilateral breast cancer, or both breast and ovarian cancer
7. A first or second degree male relative (father, brother, uncle) diagnosed with breast cancer
8. Clinical lifetime risk estimated at greater than or equal to 20% using clinical risk estimator such as the Gail, Claus, Tyrer-Cuzick or BRCAPRO models
9. Ashkenazi Jewish women from families with onset of breast cancer before age 40

Additional Risks:
 
10. Women with history of radiation to the chest between ages 10 and 30; breast screening should start 8 to 10 years post-therapy, or at age 25, whichever comes first.
11 Li-Fraumeni Syndrome (TP53 mutation) should start annual breast screening MRI starting at age 20, or at the age of the earliest diagnosed breast cancer in the family, if below age 20 years of age