When claim denials for breast ultrasounds popped up at an Illinois hospital, Jeanne Owens, the system director of billing compliance, dug in. Some physicians had ordered ultrasounds for patients with dense breasts, but Medicare doesn’t routinely cover screening breast ultrasounds unless they’re medically necessary, and dense breasts don’t necessarily qualify. That’s why the Medicare administrative contractor (MAC) was reviewing breast ultrasounds under Targeted Probe and Educate (TPE).

The audit highlights the challenge of ensuring compliance when covered diagnoses like dense breasts are in local coverage determinations (LCDs) but may not be payable, Owens said. “The list of covered diagnosis codes is not the be-all and end-all in Medicare policy,” she noted. “I focus on indications and limitations.” A corollary is the difficulty of reporting noncovered services to Medicare without triggering payment. “Just because the claim gets paid doesn’t mean it was paid correctly,” Owens said.

She added that the ultrasound denials were more than a nuisance in her state. They were a wrenching experience because a law there requires insurers to cover “a comprehensive ultrasound screening of an entire breast or breasts if a mammogram demonstrates heterogenous or dense breast tissue when medically necessary,” without patient copays, and physicians were invested in it.^[1] Some were surprised that Medicare superseded state law, Owens said.

The MAC, National Government Services (NGS), is auditing breast ultrasounds with a focus on CPT code 76641 (ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete).^[2] Fourteen physicians at her hospital were selected for the audit, and all of them had the same perception: Medicare covers ICD-10 diagnosis R92 (abnormal and inconclusive findings on diagnosis imaging of the breast) when women have dense breasts.