Radiology Coding Alert

This payer says unilateral screenings are OK

One carrier has clarified the coding issues around screening mammograms converted to diagnostic, as well as coding troublesome unilateral screening mammograms.

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, Part B carrier for New Jersey and New York. Empire will pay for both the screening and diagnostic mammograms.

What to do: You should report the screening mammography using ICD-9 code V76.11 (Special screening for malignant neoplasms; breast; screening mammogram for high-risk patient) or V76.12 (... other screening mammogram), 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 says.

You should attach modifier GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) 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, Kan.

Generally, if there are additional views ordered for a diagnostic, the radiologist will mention it somewhere in his dictated mammogram report.
 
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 76092 (Screening mammography, bilateral [two-view film study of each breast]), or G0202 (Screening mammography, producing direct digital image, bilateral, all views) combined with +76083 (Computer aided detection [computer algorithm analysis of digital image data for lesion detection] with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography).

Remember: Mammography codes change in 2007. Use 77057 for 2007 services instead of 76092. And use 77052 instead of 76083.

Essential: You should use modifier 52 (Reduced services) for unilateral screening mammograms. 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," Center says.

Resources: For Empire's policies on mammograms, take a look at "Screening Mammography, Diagnostic Mammography, and Screening Mammography That Converts to Diagnostic mammography"  (www.empiremedicare.com/news/nynews06/081506scr.htm)  and "BreastImaging:Mammography/BreastEchographySonography)/Breast
/DuctographyA40425)"  (www.empiremedicare.com/newypolicy/policy/l3500_final_guideline.htm).

Always: Check your payer's mammogram coding rules before you send in your claim.

Don't Forget the 2007 Mammo Code Changes

2006        2007
76090      77055  Mammography; unilateral

76091      77056  ... bilateral

76092      77057  Screening mammography, bilateral (two-view film study of each breast).