Recently, MMI published an article about 2018 mammography code updates and how the Centers for Medicare and Medicaid Services (CMS) have finally discarded their mammography G codes in favor of the standard CPT versions. This move will make coding for these procedures easier for practices everywhere, but unfortunately, there are still plenty of issues with other breast services, even those that already use the CPT method of coding. In particular, an update in CMS’ system somehow overlooked several breast biopsy codes, leading to an inundation of denials.

The exclusion covers multiple subsets of the N63 (Lump in Breast) code, including:

  • N63.11 (Unspecified lump in the right breast, upper outer quadrant)
  • N63.12 (Unspecified lump in the right breast, upper inner quadrant)
  • N63.13 (Unspecified lump in the right breast, lower outer quadrant)
  • N63.14 (Unspecified lump in the right breast, lower inner quadrant)
  • N63.21 (Unspecified lump in the left breast, upper outer quadrant)
  • N63.22 (Unspecified lump in the left breast, upper inner quadrant)
  • N63.23 (Unspecified lump in the left breast, lower outer quadrant)
  • N63.24 (Unspecified lump in the left breast, lower inner quadrant)
  • N63.31 (Unspecified lump in axillary tail of the right breast)
  • N63.32 (Unspecified lump in axillary tail of the left breast)
  • N63.41 (Unspecified lump in right breast, subareolar)
  • N63.42 (Unspecified lump in left breast, subareolar)

Although CMS has announced plans to correct the issue during their April 1st update, countless breast biopsy claims have already been submitted and denied. CMS has coordinated with regional Medicare administrative contractors (MACs) to fix this problem by adjusting claims, but unfortunately, these adjustments will not take place until April 2nd after the quarterly update has gone into effect. In the meantime, coders and billers should take extra care when submitting breast biopsy claims, including making special note of CMS’ error in case appealing a denial becomes necessary.