CMS Limitations Guide – Mammograms and
Bone Density Radiology Services
Starting July 1, 2008, CMS has placed numerous medical necessity limits on tests and procedures. This reference guide
provides you with all of the latest changes. This guide is not an all-inclusive list of National Coverage Documents (NCD)
and Local Coverage Documents (LCD). Please consult the CMS website for additional information at
cms.hhs.gov/mcd/search.asp?clickon=search. You can search by LCD or NCD or keyword and region.
CMS will deny payment if the correct diagnosis codes are not entered on the order form, and your patient’s test or
procedure will not be covered. We compiled this information in one location to make it easier for you to find the proper
codes for medically necessary diagnoses.
It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g. to the fourth or fifth digit).
The correct use of an ICD-9-CM code listed below does not assure coverage of a service. The service must be
reasonable and necessary in the specific case and must meet the criteria specified in this determination.
We will continue to update this list as new CMS limitations are announced. You can always find the most current list on
mymunson.org.
If you have any questions, please contact Kari Smith, Office Coordinator, at (231) 935-2296, or Karen Fouch,
Manager, Patient Access Services, at (231) 935-6164.
Screening Mammograms (L26890)....................................................................................................2
Diagnostic Mammograms (L26890) ...................................................................................................3
US Breast & MRI Breast (L26890) ......................................................................................................6
Bone Densities (L26385).....................................................................................................................8
-1-
Screening Mammograms (L26890)
V76.11
SCREENING MAMMOGRAM FOR HIGH-RISK PATIENT
V76.12
OTHER SCREENING MAMMOGRAM
-2-
Diagnostic Mammograms (L26890)
174.0
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST
174.1
MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST
174.2
MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST
174.3
MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST
174.4
MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST
174.5
MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST
174.6
MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST
174.8
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST
174.9
MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE
175.0
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST
175.9
MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST
183.0
MALIGNANT NEOPLASM OF OVARY
196.3
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF AXILLA AND UPPER
LIMB
197.0
SECONDARY MALIGNANT NEOPLASM OF LUNG
197.1
SECONDARY MALIGNANT NEOPLASM OF MEDIASTINUM
197.2
SECONDARY MALIGNANT NEOPLASM OF PLEURA
197.7
MALIGNANT NEOPLASM OF LIVER SECONDARY
198.2
SECONDARY MALIGNANT NEOPLASM OF SKIN
198.3
SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD
198.5
SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
198.81
SECONDARY MALIGNANT NEOPLASM OF BREAST
199.0
DISSEMINATED MALIGNANT NEOPLASM
199.1
OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE
217
BENIGN NEOPLASM OF BREAST
232.5
CARCINOMA IN SITU OF SKIN OF TRUNK EXCEPT SCROTUM
233.0
CARCINOMA IN SITU OF BREAST
238.2
NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN
238.3
NEOPLASM OF UNCERTAIN BEHAVIOR OF BREAST
239.2
NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN
239.3
NEOPLASM OF UNSPECIFIED NATURE OF BREAST
451.89
PHLEBITIS AND THROMBOPHLEBITIS OF OTHER SITES
610.0
SOLITARY CYST OF BREAST
-3-
610.1
DIFFUSE CYSTIC MASTOPATHY
610.2
FIBROADENOSIS OF BREAST
610.3
FIBROSCLEROSIS OF BREAST
610.4
MAMMARY DUCT ECTASIA
610.8
OTHER SPECIFIED BENIGN MAMMARY DYSPLASIAS
610.9
BENIGN MAMMARY DYSPLASIA UNSPECIFIED
611.0
INFLAMMATORY DISEASE OF BREAST
611.1
HYPERTROPHY OF BREAST
611.2
FISSURE OF NIPPLE
611.3
FAT NECROSIS OF BREAST
611.4
ATROPHY OF BREAST
611.5
GALACTOCELE
611.6
GALACTORRHEA NOT ASSOCIATED WITH CHILDBIRTH
611.71
MASTODYNIA
611.72
LUMP OR MASS IN BREAST
611.79
OTHER SIGNS AND SYMPTOMS IN BREAST
611.83
CAPSULAR CONTRACTURE OF BREAST IMPLANT
611.89*
OTHER SPECIFIED DISORDERS OF BREAST
611.9
UNSPECIFIED BREAST DISORDER
612.0
DEFORMITY OF RECONSTRUCTED BREAST
612.1
DISPROPORTION OF RECONSTRUCTED BREAST
785.6
ENLARGEMENT OF LYMPH NODES
793.80
UNSPECIFIED ABNORMAL MAMMOGRAM
793.81
MAMMOGRAPHIC MICROCALCIFICATION
793.82
INCONCLUSIVE MAMMOGRAM
793.89
OTHER (ABNORMAL) FINDINGS ON RADIOLOGICAL EXAMINATION OF BREAST
879.0
OPEN WOUND OF BREAST WITHOUT COMPLICATION
879.1
OPEN WOUND OF BREAST COMPLICATED
922.0
CONTUSION OF BREAST
996.54
MECHANICAL COMPLICATION OF BREAST PROSTHESIS
996.69
INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL PROSTHETIC DEVICE
IMPLANT AND GRAFT
V10.3
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST
V10.89* PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES
V15.89
-4-
OTHER SPECIFIED PERSONAL HISTORY PRESENTING HAZARDS TO HEALTH
V45.83* BREAST IMPLANT REMOVAL STATUS
V67.1
FOLLOW-UP EXAMINATION FOLLOWING RADIOTHERAPY
V67.2
FOLLOW-UP EXAMINATION FOLLOWING CHEMOTHERAPY
V71.1
OBSERVATION FOR SUSPECTED MALIGNANT NEOPLASM
*Use ICD-9-CM code 611.89 for hematoma
*ICD-9-CM codes V10.89 and V45.83 may be reported only until clinical stability has been established.
-5-
US Breast & MRI Breast (L26890)
174.0
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST
174.1
MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST
174.2
MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST
174.3
MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST
174.4
MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST
174.5
MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST
174.6
MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST
174.8
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST
174.9
MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE
175.0
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST
175.9
MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST
196.3
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF AXILLA AND UPPER
LIMB
198.2
SECONDARY MALIGNANT NEOPLASM OF SKIN
198.81
SECONDARY MALIGNANT NEOPLASM OF BREAST
199.1
OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE
217
BENIGN NEOPLASM OF BREAST
233.0
CARCINOMA IN SITU OF BREAST
238.3
NEOPLASM OF UNCERTAIN BEHAVIOR OF BREAST
239.2
NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN
239.3
NEOPLASM OF UNSPECIFIED NATURE OF BREAST
610.0
SOLITARY CYST OF BREAST
610.1*
DIFFUSE CYSTIC MASTOPATHY
610.2*
FIBROADENOSIS OF BREAST
610.3*
FIBROSCLEROSIS OF BREAST
610.4*
MAMMARY DUCT ECTASIA
610.8*
OTHER SPECIFIED BENIGN MAMMARY DYSPLASIAS
610.9*
BENIGN MAMMARY DYSPLASIA UNSPECIFIED
611.0
INFLAMMATORY DISEASE OF BREAST
611.1
HYPERTROPHY OF BREAST
611.2*
FISSURE OF NIPPLE
611.3*
FAT NECROSIS OF BREAST
611.4*
ATROPHY OF BREAST
-6-
611.5*
GALACTOCELE
611.6*
GALACTORRHEA NOT ASSOCIATED WITH CHILDBIRTH
611.71
MASTODYNIA
611.72
LUMP OR MASS IN BREAST
611.79
OTHER SIGNS AND SYMPTOMS IN BREAST
611.89* OTHER SPECIFIED DISORDERS OF BREAST
611.9*
UNSPECIFIED BREAST DISORDER
612.0
DEFORMITY OF RECONSTRUCTED BREAST
612.1
DISPROPORTION OF RECONSTRUCTED BREAST
793.80
UNSPECIFIED ABNORMAL MAMMOGRAM
793.81
MAMMOGRAPHIC MICROCALCIFICATION
793.82
INCONCLUSIVE MAMMOGRAM
793.89
OTHER (ABNORMAL) FINDINGS ON RADIOLOGICAL EXAMINATION OF BREAST
996.54
MECHANICAL COMPLICATION OF BREAST PROSTHESIS
996.69
INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL PROSTHETIC DEVICE
IMPLANT AND GRAFT
V10.3
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST
-7-
Bone Densities (L26385)
ICD-9-CM code 733.13 should be reported for collapse of vertebrae NOS.
ICD-9-CM code 793.7 should be reported as a secondary diagnosis when DXA is performed for subsequent monitoring
following a BMM performed by another modality.
ICD-9-CM code V45.77 should be reported for women s/p oophorectomy.
ICD-9-CM code V58.65 should be reported for an individual on glucocorticoid therapy.
ICD-9-CM code V58.69 should be reported for DXA testing while taking medicines for osteoporosis/osteopenia.
ICD-9-CM code V67.51 should be reported for an individual who has COMPLETED drug therapy for osteoporosis and is
being monitored for response to therapy.
ICD-9-CM code 733.90 should be reported to indicate osteopenia, (only when billing 77080-DXA), when used to follow
treatment with FDA approved osteoporosis medications.
For Bone Density CPT 77080 Only:
255.0
CUSHING'S SYNDROME
733.00 OSTEOPOROSIS UNSPECIFIED
733.01
SENILE OSTEOPOROSIS
733.02
IDIOPATHIC OSTEOPOROSIS
733.03
DISUSE OSTEOPOROSIS
733.09
OTHER OSTEOPOROSIS
733.90
DISORDER OF BONE AND CARTILAGE UNSPECIFIED
V58.65 LONG-TERM (CURRENT) USE OF STEROIDS
V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT
ELSEWHERE CLASSIFIED
These following diagnoses may support medical necessity for CPT codes 77078, 77079, 77080, 77081, 77083, 76977
and G0130, when these tests are performed for bone mass density screening for potential osteopenia/osteoporosis
in qualified beneficiaries with estrogen deficiency, vertebral abnormalities/fractures, primary
hyperparathyroidism or glucocorticoid administration
252.01
PRIMARY HYPERPARATHYROIDISM
256.2
POSTABLATIVE OVARIAN FAILURE
256.31
PREMATURE MENOPAUSE
256.39
OTHER OVARIAN FAILURE
259.3
ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED
627.0
PREMENOPAUSAL MENORRHAGIA
627.1
POSTMENOPAUSAL BLEEDING
627.2
SYMPTOMATIC MENOPAUSAL OR FEMALE CLIMACTERIC STATES
627.3
POSTMENOPAUSAL ATROPHIC VAGINITIS
627.4
SYMPTOMATIC STATES ASSOCIATED WITH ARTIFICIAL MENOPAUSE
-8-
627.8
OTHER SPECIFIED MENOPAUSAL AND POSTMENOPAUSAL DISORDERS
627.9
UNSPECIFIED MENOPAUSAL AND POSTMENOPAUSAL DISORDER
733.13
PATHOLOGICAL FRACTURE OF VERTEBRAE
756.51
OSTEOGENESIS IMPERFECTA
758.6
GONADAL DYSGENESIS
793.7
NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF
MUSCULOSKELETAL SYSTEM
805.00
CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL
805.01
CLOSED FRACTURE OF FIRST CERVICAL VERTEBRA
805.02
CLOSED FRACTURE OF SECOND CERVICAL VERTEBRA
805.03
CLOSED FRACTURE OF THIRD CERVICAL VERTEBRA
805.04
CLOSED FRACTURE OF FOURTH CERVICAL VERTEBRA
805.05
CLOSED FRACTURE OF FIFTH CERVICAL VERTEBRA
805.06
CLOSED FRACTURE OF SIXTH CERVICAL VERTEBRA
805.07
CLOSED FRACTURE OF SEVENTH CERVICAL VERTEBRA
805.08
CLOSED FRACTURE OF MULTIPLE CERVICAL VERTEBRAE
805.10
OPEN FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL
805.11
OPEN FRACTURE OF FIRST CERVICAL VERTEBRA
805.12
OPEN FRACTURE OF SECOND CERVICAL VERTEBRA
805.13
OPEN FRACTURE OF THIRD CERVICAL VERTEBRA
805.14
OPEN FRACTURE OF FOURTH CERVICAL VERTEBRA
805.15
OPEN FRACTURE OF FIFTH CERVICAL VERTEBRA
805.16
OPEN FRACTURE OF SIXTH CERVICAL VERTEBRA
805.17
OPEN FRACTURE OF SEVENTH CERVICAL VERTEBRA
805.18
OPEN FRACTURE OF MULTIPLE CERVICAL VERTEBRAE
805.2
CLOSED FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY
805.3
OPEN FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY
805.4
CLOSED FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY
805.5
OPEN FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY
805.6
CLOSED FRACTURE OF SACRUM AND COCCYX WITHOUT SPINAL CORD INJURY
805.7
OPEN FRACTURE OF SACRUM AND COCCYX WITHOUT SPINAL CORD INJURY
805.8
CLOSED FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY
805.9
OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY
806.00
CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY
806.01
CLOSED FRACTURE OF C1-C4 LEVEL WITH COMPLETE LESION OF CORD
-9-
806.02
CLOSED FRACTURE OF C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME
806.03
CLOSED FRACTURE OF C1-C4 LEVEL WITH CENTRAL CORD SYNDROME
806.04
CLOSED FRACTURE OF C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY
806.05
CLOSED FRACTURE OF C5-C7 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY
806.06
CLOSED FRACTURE OF C5-C7 LEVEL WITH COMPLETE LESION OF CORD
806.07
CLOSED FRACTURE OF C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME
806.08
CLOSED FRACTURE OF C5-C7 LEVEL WITH CENTRAL CORD SYNDROME
806.09
CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY
806.10
OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY
806.11
OPEN FRACTURE OF C1-C4 LEVEL WITH COMPLETE LESION OF CORD
806.12
OPEN FRACTURE OF C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME
806.13
OPEN FRACTURE OF C1-C4 LEVEL WITH CENTRAL CORD SYNDROME
806.14
OPEN FRACTURE OF C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY
806.15
OPEN FRACTURE OF C5-C7 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY
806.16
OPEN FRACTURE OF C5-C7 LEVEL WITH COMPLETE LESION OF CORD
806.17
OPEN FRACTURE OF C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME
806.18
OPEN FRACTURE OF C5-C7 LEVEL WITH CENTRAL CORD SYNDROME
806.19
OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY
806.20
CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY
806.21
CLOSED FRACTURE OF T1-T6 LEVEL WITH COMPLETE LESION OF CORD
806.22
CLOSED FRACTURE OF T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME
806.23
CLOSED FRACTURE OF T1-T6 LEVEL WITH CENTRAL CORD SYNDROME
806.24
CLOSED FRACTURE OF T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY
806.25
CLOSED FRACTURE OF T7-T12 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY
806.26
CLOSED FRACTURE OF T7-T12 LEVEL WITH COMPLETE LESION OF CORD
806.27
CLOSED FRACTURE OF T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME
806.28
CLOSED FRACTURE OF T7-T12 LEVEL WITH CENTRAL CORD SYNDROME
806.29
CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY
806.30
OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY
806.31
OPEN FRACTURE OF T1-T6 LEVEL WITH COMPLETE LESION OF CORD
806.32
OPEN FRACTURE OF T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME
806.33
OPEN FRACTURE OF T1-T6 LEVEL WITH CENTRAL CORD SYNDROME
806.34
OPEN FRACTURE OF T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY
806.35
OPEN FRACTURE OF T7-T12 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY
806.36
OPEN FRACTURE OF T7-T12 LEVEL WITH COMPLETE LESION OF CORD
- 10 -
806.37
OPEN FRACTURE OF T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME
806.38
OPEN FRACTURE OF T7-T12 LEVEL WITH CENTRAL CORD SYNDROME
806.39
OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY
806.4
CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY
806.5
OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY
806.60
CLOSED FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY
806.61
CLOSED FRACTURE OF SACRUM AND COCCYX WITH COMPLETE CAUDA EQUINA LESION
806.62
CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY
806.69
CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY
806.70
OPEN FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY
806.71
OPEN FRACTURE OF SACRUM AND COCCYX WITH COMPLETE CAUDA EQUINA LESION
806.72
OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY
806.79
OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY
806.8
CLOSED FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY
806.9
OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY
E932.0 ADRENAL CORTICAL STEROIDS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
V45.77 ACQUIRED ABSENCE OF ORGAN GENITAL ORGANS
V49.81 ASYMPTOMATIC POSTMENOPAUSAL STATUS (AGE-RELATED) (NATURAL)
V58.65 LONG-TERM (CURRENT) USE OF STEROIDS
- 11 -