Part B Insider (Multispecialty) Coding Alert

Published on Sat Aug 26, 2006 PDF

You can bill a unilateral screening mammography, carrier says

Heads up: One carrier has clarified the billing issues around screening mammograms that turn diagnostic, and your carrier may follow suit.

The issue: If a patient comes in for a screening mammogram and the doctor sees something that requires further study, you can bill for extra views using diagnostic codes, says Empire Medicare. Empire will pay for both the screening and diagnostic mammograms.

What to do: You should bill for the screening mammography using ICD-9 code V76.11 or V76.12, says Empire. For the diagnostic mammogram, you should use one of the ICD-9 codes that Empire lists in its local coverage determination for diagnostic mammography, or screening mammography that converts to diagnostic.

You should bill for the screening and diagnostic mammograms on the same claim, Empire instructs. You should attach the GG modifier to the diagnostic code to show that the test changed from a screening to a diagnostic mammogram.

Usually, you can tell if a screening mammogram turns diagnostic because the screening and diagnostic mammograms will be on different reports, says Lisa Center, certified professional coder with Mount Carmel Regional Medical Center in Wichita, KS.

-Generally, if there are additional views ordered for a diagnostic, the radiologist will mention it somewhere in his dictated mammogram report,- says coder Audra Begley.

Important: Many coders have questioned whether a unilateral mammogram can ever be billed as a screening mammogram. Chances are, the doctor is only checking one breast because the patient already had a mastectomy or problems with one breast in particular.

But Empire says you can bill a unilateral screening mammography using CPT code 76092, or G0202 combined with 76083. You should use the 52 modifier (Reduced services) for unilateral screening mastectomies. Empire will pay for this service at 75 percent of the payment for a bilateral mammogram.

Often, enough time has passed since the patient had cancer that she and her doctor decide that a screening mammogram is enough, says Donna Richmond with CodeRyte in Bethesda, MD.

-If a patient has had a mastectomy and is back for a routine screening, we bill [the tests] as screenings with a high risk diagnosis,- reports Center.

Caution: Some Part B carriers won't ever pay for a unilateral screening mammogram, warns Stacy Hardy, coding specialist with Sierra Vista Diagnostics in Sierra Vista, AZ. She usually has to resubmit the claims as diagnostic before her carrier will pay them.