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CMS Transmittals



National Coverage Determination
Procedure Code: G0279
Mammograms
CMS Policy Number: 220.4
Back to NCD List



To review all requirements of this policy, please see: CMS NCD listing by Chapter

Covered ICD-10 Codes.

ICD-10Descriptor
C43.52 Malignant melanoma of skin of breast
C43.59 Malignant melanoma of other part of trunk
C44.501 Unspecified malignant neoplasm of skin of breast
C44.509 Unsp malignant neoplasm of skin of other part of trunk
C44.511 Basal cell carcinoma of skin of breast
C44.519 Basal cell carcinoma of skin of other part of trunk
C44.521 Squamous cell carcinoma of skin of breast
C44.529 Squamous cell carcinoma of skin of other part of trunk
C44.591 Other specified malignant neoplasm of skin of breast
C44.599 Oth malignant neoplasm of skin of other part of trunk
C45.9 Mesothelioma, unspecified
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.211 Malig neoplm of upper-inner quadrant of right female breast
C50.212 Malig neoplasm of upper-inner quadrant of left female breast
C50.221 Malig neoplasm of upper-inner quadrant of right male breast
C50.222 Malig neoplasm of upper-inner quadrant of left male breast
C50.311 Malig neoplm of lower-inner quadrant of right female breast
C50.312 Malig neoplasm of lower-inner quadrant of left female breast
C50.321 Malig neoplasm of lower-inner quadrant of right male breast
C50.322 Malig neoplasm of lower-inner quadrant of left male breast
C50.411 Malig neoplm of upper-outer quadrant of right female breast
C50.412 Malig neoplasm of upper-outer quadrant of left female breast
C50.421 Malig neoplasm of upper-outer quadrant of right male breast
C50.422 Malig neoplasm of upper-outer quadrant of left male breast
C50.511 Malig neoplm of lower-outer quadrant of right female breast
C50.512 Malig neoplasm of lower-outer quadrant of left female breast
C50.521 Malig neoplasm of lower-outer quadrant of right male breast
C50.522 Malig neoplasm of lower-outer quadrant of left male breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.811 Malignant neoplasm of ovrlp sites of right female breast
C50.812 Malignant neoplasm of ovrlp sites of left female breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C50.911 Malignant neoplasm of unsp site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.921 Malignant neoplasm of unspecified site of right male breast
C50.922 Malignant neoplasm of unspecified site of left male breast
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C77.3 Sec and unsp malig neoplasm of axilla and upper limb nodes
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.1 Secondary malignant neoplasm of mediastinum
C78.2 Secondary malignant neoplasm of pleura
C78.7 Secondary malig neoplasm of liver and intrahepatic bile duct
C79.2 Secondary malignant neoplasm of skin
C79.31 Secondary malignant neoplasm of brain
C79.32 Secondary malignant neoplasm of cerebral meninges
C79.40 Secondary malignant neoplasm of unsp part of nervous system
C79.49 Secondary malignant neoplasm of oth parts of nervous system
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
C79.61 Secondary malignant neoplasm of right ovary
C79.62 Secondary malignant neoplasm of left ovary
C79.81 Secondary malignant neoplasm of breast
C80.0 Disseminated malignant neoplasm, unspecified
C80.1 Malignant (primary) neoplasm, unspecified
D03.52 Melanoma in situ of breast (skin) (soft tissue)
D03.59 Melanoma in situ of other part of trunk
D04.5 Carcinoma in situ of skin of trunk
D05.01 Lobular carcinoma in situ of right breast
D05.02 Lobular carcinoma in situ of left breast
D05.11 Intraductal carcinoma in situ of right breast
D05.12 Intraductal carcinoma in situ of left breast
D05.81 Other specified type of carcinoma in situ of right breast
D05.82 Other specified type of carcinoma in situ of left breast
D05.91 Unspecified type of carcinoma in situ of right breast
D05.92 Unspecified type of carcinoma in situ of left breast
D22.5 Melanocytic nevi of trunk
D23.5 Other benign neoplasm of skin of trunk
D24.1 Benign neoplasm of right breast
D24.2 Benign neoplasm of left breast
D48.5 Neoplasm of uncertain behavior of skin
D48.61 Neoplasm of uncertain behavior of right breast
D48.62 Neoplasm of uncertain behavior of left breast
D49.1 Neoplasm of unspecified behavior of respiratory system
D49.2 Neoplasm of unsp behavior of bone, soft tissue, and skin
D49.3 Neoplasm of unspecified behavior of breast
D49.6 Neoplasm of unspecified behavior of brain
D49.7 Neoplm of unsp behav of endo glands and oth prt nervous sys
I80.8 Phlebitis and thrombophlebitis of other sites
M70.80 Oth soft tissue disord related to use/pressure of unsp site
M70.88 Oth soft tissue disorders related to use/pressure oth site
M70.89 Oth soft tissue disord related to use/pressure mult sites
M70.90 Unsp soft tissue disord related to use/pressure of unsp site
M70.98 Unsp soft tissue disorder related to use/pressure oth
M70.99 Unsp soft tissue disord related to use/pressure mult sites
M79.5 Residual foreign body in soft tissue
M79.81 Nontraumatic hematoma of soft tissue
M79.89 Other specified soft tissue disorders
M79.9 Soft tissue disorder, unspecified
N60.01 Solitary cyst of right breast
N60.02 Solitary cyst of left breast
N60.11 Diffuse cystic mastopathy of right breast
N60.12 Diffuse cystic mastopathy of left breast
N60.21 Fibroadenosis of right breast
N60.22 Fibroadenosis of left breast
N60.31 Fibrosclerosis of right breast
N60.32 Fibrosclerosis of left breast
N60.41 Mammary duct ectasia of right breast
N60.42 Mammary duct ectasia of left breast
N60.81 Other benign mammary dysplasias of right breast
N60.82 Other benign mammary dysplasias of left breast
N60.91 Unspecified benign mammary dysplasia of right breast
N60.92 Unspecified benign mammary dysplasia of left breast
N61.0 Mastitis without abscess
N61.1 Abscess of the breast and nipple
N62 Hypertrophy of breast
N63.10 Unspecified lump in the right breast, unspecified quadrant
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
N63.20 Unspecified lump in the left breast, unspecified 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
N64.0 Fissure and fistula of nipple
N64.1 Fat necrosis of breast
N64.2 Atrophy of breast
N64.3 Galactorrhea not associated with childbirth
N64.4 Mastodynia
N64.51 Induration of breast
N64.52 Nipple discharge
N64.53 Retraction of nipple
N64.59 Other signs and symptoms in breast
N64.81 Ptosis of breast
N64.82 Hypoplasia of breast
N64.89 Other specified disorders of breast
N64.9 Disorder of breast, unspecified
N65.0 Deformity of reconstructed breast
N65.1 Disproportion of reconstructed breast
R59.0 Localized enlarged lymph nodes
R59.1 Generalized enlarged lymph nodes
R59.9 Enlarged lymph nodes, unspecified
R92.0 Mammographic microcalcification found on dx imaging of brst
R92.1 Mammographic calcifcn found on diagnostic imaging of breast
R92.2 Inconclusive mammogram
R92.8 Oth abn and inconclusive findings on dx imaging of breast
R93.9 Dx imaging inconclusive due to excess body fat of patient
S20.01XA Contusion of right breast, initial encounter
S20.02XA Contusion of left breast, initial encounter
S21.001A Unspecified open wound of right breast, initial encounter
S21.002A Unspecified open wound of left breast, initial encounter
S21.011A Laceration without foreign body of right breast, init encntr
S21.012A Laceration without foreign body of left breast, init encntr
S21.021A Laceration with foreign body of right breast, init encntr
S21.022A Laceration with foreign body of left breast, init encntr
S21.031A Puncture wound w/o foreign body of right breast, init encntr
S21.032A Puncture wound w/o foreign body of left breast, init encntr
S21.041A Puncture wound w foreign body of right breast, init encntr
S21.042A Puncture wound with foreign body of left breast, init encntr
S21.051A Open bite of right breast, initial encounter
S21.052A Open bite of left breast, initial encounter
S28.211A Complete traumatic amputation of right breast, init encntr
S28.212A Complete traumatic amputation of left breast, init encntr
S28.221A Partial traumatic amputation of right breast, init encntr
S28.222A Partial traumatic amputation of left breast, init encntr
S29.001A Unsp injury of msl/tnd of front wall of thorax, init
S29.009A Unsp injury of msl/tnd of unsp wall of thorax, init
S29.091A Inj muscle and tendon of front wall of thorax, init encntr
S29.099A Inj muscle and tendon of unsp wall of thorax, init encntr
S29.8XXA Other specified injuries of thorax, initial encounter
S29.9XXA Unspecified injury of thorax, initial encounter
S39.001A Unsp injury of muscle, fascia and tendon of abdomen, init
S39.091A Inj muscle, fascia and tendon of abdomen, init encntr
S39.81XA Other specified injuries of abdomen, initial encounter
S39.91XA Unspecified injury of abdomen, initial encounter
T85.41XA Breakdown of breast prosthesis and implant, init
T85.42XA Displacement of breast prosthesis and implant, init encntr
T85.43XA Leakage of breast prosthesis and implant, initial encounter
T85.44XA Capsular contracture of breast implant, initial encounter
T85.49XA Mech compl of breast prosthesis and implant, init encntr
T85.79XA Infect/inflm reaction due to oth int prosth dev/grft, init
Z03.89 Encntr for obs for oth suspected diseases and cond ruled out
Z08 Encntr for follow-up exam after trtmt for malignant neoplasm
Z77.123 Cntct w & expsr to radon and other naturally occur radiation
Z77.128 Contact w and expsr to oth hazards in the physcl environment
Z77.9 Oth contact w and (suspected) exposures hazardous to health
Z85.3 Personal history of malignant neoplasm of breast
Z85.831 Personal history of malignant neoplasm of soft tissue
Z85.89 Personal history of malignant neoplasm of organs and systems
Z86.000 Personal history of in-situ neoplasm of breast
Z91.89 Oth personal risk factors, not elsewhere classified
Z92.89 Personal history of other medical treatment
Z98.82 Breast implant status
Z98.86 Personal history of breast implant removal

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