Oncology & Hematology Coding Alert

Recently, U.S. Health and Human Services Secretary Tommy Thompson reaffirmed the importance of mammograms for women 40 years of age and older. Although the announcement bodes well for expanding coverage of mammogram screenings among payers who limit coverage to women who are age 50 and older, it will have no effect on diagnostic mammograms. Oncology practices must still provide proper ICD-9 codes to avoid the diagnostic procedure from being mistaken as a noncovered screening.

Diagnostic mammograms are more common than screenings for oncologists because they usually see patients if there are symptoms. Failure to distinguish a diagnostic mammography (76090-76091) from a screening could lead to denials, says Nancy Giacomozzi, manager of P.K. Administrative Services, a medical billing company in Lakewood, Colo. Focus on Symptoms Although age and frequency determine reimbursement for screenings, payment for diagnostic mammography depends on diagnosis codes that support its medical necessity (see sidebar on page 42), says Paula Stinecipher, CPC, co-founder and president of AlphaQuest, an Atlanta-based coding and consulting firm.

In general, Medicare pays for diagnostic mammograms based on the following: Breast changes that persist, such as a lump, thickening, swelling, dimpling, skin irritation, distortion, retraction or scaliness of the nipple, nipple discharge, nodularity or breast tenderness Follow-up of abnormal mammogram Conversion of a screening mammogram to a diagnostic mammogram. Aside from 76090-76091, Medicare recognizes three temporary codes for mammography procedures that produce digital imagery: G0204 Diagnostic mammography, producing direct digital image, bilateral, all views G0206 unilateral, all views G0236 Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, diagnostic mammography (list separately in addition to code for primary procedure). Although women with a family history of breast cancer are at high risk, their history alone is not enough to support medical necessity for a diagnostic mammography. Instead, payers will interpret a mammogram performed within one year of the last screening as medically unnecessary. However, a woman who seeks care after discovering a breast lump (611.72) will require a diagnostic mammogram regardless of when her last screening took place. Scenarios Distinguish Diagnostic From Screening The following scenarios illustrate how to distinguish a diagnostic mammography from a screening: Diagnostic procedure performed before next covered screening. A 40-year-old woman notices a lump in her breast six months after her last screening. Other than symptoms of cancer, there is no cancer diagnosis code to show that the procedure is more than a screening. But Medicare and other payers allow reimbursement for diagnostic mammograms based on specific symptoms that indicate the potential for breast cancer. The proper diagnosis code would be 611.72 (Lump or mass in breast) and the procedure code would be 76090 (Mammography; unilateral). Routine screening shows abnormality and [...]