Mammography

I. Description

Screening mammography

Starting January 1, 2017, HMSA’s Commercial plans and QUEST Integration plans cover a screening mammography for women one every calendar year beginning at age 40 years old. A woman of any age with a personal history of breast cancer (ICD-10-CM: Z85.3), whose mother or sister has a history of breast cancer (ICD-10-CM: Z80.3) is eligible for a screening mammography when ordered by her physician. This is consistent with the recommendations provided by the United States Preventive Services Task Force, the American Cancer Society and the American College of Obstetricians and Gynecologists.

Note: Medicare Advantage members continue to get one baseline screening mammography ages 35 years through 39 years old and once every calendar year for women ages 40 years and older.

Starting July 1, 2019, a screening digital breast tomosynthesis (3D) is covered. Please refer to the Digital Breast Tomosynthesis policy for additional information.

Diagnostic mammography

Diagnostic mammography is appropriate for women who are symptomatic. Follow-up diagnostic mammography is also eligible for coverage when a previous screening mammography shows abnormal findings. The follow-up mammography must be billed with an ICD-10-CM code that accurately reflects the patient’s symptoms or reflects previous abnormal findings.

Benefits are available for diagnostic mammography as ordered by a physician. Annual screening limits do not apply.

II. Claims Filing Information

The codes referenced below may be billed for screening Mammography.

For screening mammography:

For professional claims, the applicable ICD-10 code must be identified as the primary line diagnosis to ensure appropriate application of benefits.

For diagnostic mammography:

If claims are filed by a facility on the UB-04, please use type of bill 0131 and the appropriate provider ID number for outpatient services.

Revision History