Even though it is a common imaging procedure, mammography offers no shortage of bewildering questions for radiology coders. At the heart of the confusion are issues that cloud the distinctions between screening and diagnostic mammogramsdistinctions that make coding for patients who have been treated for breast cancer especially challenging.
Professional coders across the country report wildly different local Medicare policies regulating mammograms for former breast cancer patients, and stress the need for imaging centers to keep current of local requirements that affect reimbursement levels.
Is History of Breast Cancer Justification?
Many local policies follow the lead of the Health Care Financing Administration (HCFA) and allow radiologists to assign diagnostic mammography codes (76090, mammography; unilateral; or 76091, bilateral) to patients who have had a personal history of breast cancer.
For example, the local Medicare policy in Pennsylvania allows reimbursement for diagnostic mammograms for men or women who have a personal history of breast cancer (V10.3), along with those who exhibit signs and symptoms of breast disease (i.e., lump or mass in the breast611.72) or have a personal history of biopsy-proven benign breast disease (i.e., solitary cyst of breast610.0).
Similar coding requirements can be found in
Connecticut. According to Darlene Zase, BS, CMPE, administrative director for Bridgeport Radiology Association in Fairfield, Conn., radiologists there are allowed to bill mammography as diagnostic for at least five years after patients have been treated for cancer. (Five years post-therapy is often accepted by medial professionals as the point when cancer treatment can be considered successful.)
When Diagnostic Mammograms Are Allowed
Other payers, however, have implemented restrictions on diagnostic mammograms for post-treatment breast cancer patients.
One
Radiology Coder in Washington state, for instance, has observed a recent policy change that restricts radiologists ability to assign the diagnostic mammography code. I had always assumed there was a national policy on this, she says. But we have begun seeing rejections from Medicare for diagnostic mammograms on patients who are three or more years post-treatment and are asymptomatic. This seems like a very arbitrary time frame to definitively state that mammograms that had been diagnostic now suddenly become screening (76092, screening mammography, bilateral [two view film study of each breast]).
According to April Brazinsky, CCS, coding specialist for the Community Hospital of the Monterey Peninsula in California, colleagues throughout the country share this coders frustration. We are seeing time frames like this established by local carriers or fiscal intermediaries everywhereand there are great differences from region to region.
Brazinsky notes that, in her area, the regulations are far more conservative than three years. Here in northern California, our regulations state that a screening mammogram must be ordered unless the patient has current cancer symptoms. Once [...]
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