Correct coding for mri exam needed resulting from abnormal mammogram.

Gran1234

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I work for an mri company and code reports from the radiologist. In many cases the patient is coming in for an mri for reason of "abnormal mammogram". Sometimes the diagnosis will state from the mri report "benign cystic masses". I typically use this diagnosis code when submitting a claim. Am i coding incorrectly. I have been getting denials from insurance stating "not covered due to experimental or investigational are excluded from coverage". I always thought that the actual report overrides the reason for the mri as being "abnormal mammogram".
Thanks for any suggestions.
 
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I work for an mri company and code reports from the radiologist. In many cases the patient is coming in for an mri for reason of "abnormal mammogram". Sometimes the diagnosis will state from the mri report "benign cystic masses". I typically use this diagnosis code when submitting a claim. Am i coding incorrectly. I have been getting denials from insurance stating "not covered due to experimental or investigational are excluded from coverage". I always thought that the actual report overrides the reason for the mri as being "abnormal mammogram".
Thanks for any suggestions.

I completely understand what you're saying. But perhaps think of it from a payer's perspective. They get a claim for an MRI and a diagnosis of benign cystic masses; they have no idea that the MRI was done due to abnormal findings. And those findings weren't established until after the MRI, so they wouldn't necessarily know that either. So it may look like an MRI was done for a reason that's not really necessary if the provider has already established the "diagnosis."

There are also tons of rules regarding mammograms, particularly with Medicare. What codes are you billing? Are these denials coming from MC primarily or is it just across the board?
 

Gran1234

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Diag. Coding of breast mri

I have not been coding the "abnormal mammogram" but just the cyst. Aetna would have paid for the code for "abnormal mammogram" but not for the cyst.
 
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I have not been coding the "abnormal mammogram" but just the cyst. Aetna would have paid for the code for "abnormal mammogram" but not for the cyst.

I did a random search for Aetna and found this:

"Aetna considers breast MRI experimental and investigational for all other indications, including any of the following, because there is insufficient scientific evidence to support its use:

To confirm implant rupture in symptomatic individuals whose ultrasonography shows rupture, especially with implants more than 10 years old (ultrasound sufficient to proceed with removal); or
To diagnose fat necrosis post-breast reduction surgery; or
To differentiate benign from malignant breast disease, especially clustered micro-calcifications; or
To differentiate cysts from solid lesions (ultrasound indicated); or
To evaluate breasts before biopsy in an effort to reduce the number of surgical biopsies for benign lesions; or
Surveillance of asymptomatic individuals with breast cancer who have completed primary therapy and who are not at high genetic risk of breast cancer; or
To provide an early prediction of response to adjuvant breast cancer chemotherapy in guiding choice of chemotherapy regimen; or
Dermatomyositis as an indication for use of MRI for breast cancer screening; or
To screen for breast cancer in members with average risk of breast cancer; or
To screen BRCA-positive men.

ICD-10 codes not covered for indications listed in the CPB:

D24.1 - D24.9 Benign neoplasm of breast
D48.60 - D48.69 Neoplasm of uncertain behavior of breast
M33.00 - M33.99 Dermatopolymyositis
N60.01 - N60.09 Solitary cyst of breast
N60.11 - N60.19 Diffuse cystic mastopathy
N60.21 - N60.29 Fibroadenosis of breast
N60.81 - N60.89 Other benign mammary dysplasias
N64.1- Fat necrosis of breast
N64.9 Disorder of breast, unspecified
R92.0 Mammographic microcalcification found on diagnostic imaging of breast
R99 Ill-defined and unknown cause of mortality"


This is covered if criteria are met: "R92.8 Other abnormal and inconclusive findings on diagnostic imaging of breast"

http://www.aetna.com/cpb/medical/data/100_199/0105.html
The date on the document is old, but there's been very recent revisions that you can see when you click on the box.

I don't know if this will be helpful, but there's some coding examples.
https://rccb.org/icd-10-cm-codes-for-mammograms
 
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