Epithelial Cell Cytology in Breast
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This reimbursement policy governs coverage and payment for cytologic analysis of epithelial cells from the breast (e.g., nipple aspiration, fine-needle aspiration) and applies to Blue Cross Blue Shield - New Mexico products and participating providers submitting claims to BCBSNM.
Edited Reimbursement Information to clarify situations where epithelial cell cytology is not reimbursable and added examples (e.g., nipple aspiration, fine-needle aspiration [FNA]).
Added CPT codes 88172, 88173, 88177 to the procedure code list.
Coverage Criteria
Non-reimbursable services
Reimbursement stance
Covered Indications
Coding
Provider Actions & Claims
Documentation and claim submission requirements
Providers must submit accurate documentation of services performed and file claims using valid code combinations from HIPAA‑approved code sets. Claims are subject to code-edit protocols and review against benefit coverage, provider contract terms, medical and reimbursement policies, and coding software logic; upon request, providers should submit additional documentation.
- Use industry-standard coding guidelines (e.g., Uniform Billing Editor, AMA CPT, HCPCS, ICD-10-CM/PCS).
- Submit claims with appropriate code combinations per CMS National Correct Coding Initiative and CCI edits.
- Respond to requests for additional documentation to support the claim.
Ordering Requirements
Follow Plan documents and provider contracts for ordering
Plan documents and applicable provider contracts govern coverage determinations; providers should follow those Plan-specific requirements when ordering services.
- Review member-specific Plan documents (Certificates, Benefit Booklets, Summary Plan Descriptions) for coverage details.
- Follow provider contract language where it conflicts with the reimbursement policy.
Definitions
Frequency Limits
Not Covered
Blue Cross Blue Shield of New Mexico does not reimburse cytologic analysis of epithelial cells from the breast for any of the following purposes: diagnosis, screening, or assessment of cancer risk. This includes specimen-procurement examples such as nipple aspiration and fine-needle aspiration (FNA).
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