Take This Advice to Code Screening Mammograms Correctly
Question: I am still confused about the correct way to code for a screening mammography, especially if the screen results in an abnormal finding. Is it still considered a screening followed by an abnormal diagnosis or just an abnormal diagnosis? Revenue Cycle Insider Subscriber Answer: The answers to your questions can be found in ICD-10-CM Guideline I.C.21.c.5. The guideline explains that, in encounters such as these, “screening is the testing for disease or disease precursors in seemingly well individuals.” The guideline goes on to tell you “a screening code may be a first-listed code if the reason for the visit is specifically the screening exam.” So, in your situation, Z12.31 (Encounter for screening mammogram for malignant neoplasm of breast) would be the first-listed code, assuming the patient has not presented with any symptoms prior to the encounter. The guideline then says, “Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.” This would then lead you to assign a code such as N63.- (Unspecified lump in breast) to document the incidental mammogram finding. Should a patient report with symptoms of a specific condition, however, the guideline is clear that the encounter can no longer be coded as a screening. At this point, the encounter is regarded as “a diagnostic examination, not a screening” and “the sign or symptom is used to explain the reason for the test,” per the guideline. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
