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Wiki Modifier 52 for G0202/G0206

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pennylpalmer

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Oro Valley, AZ
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We have been billing G0202 52 , with G0206 LT. Medicare is denying payment of the G0202 for bundling. I cannot find any information stating that you can no longer use the modifier 52 for a reduced service on a screening mammogram nor can I find any information that states you cannot bill G0202 with G0206. Does anyone have any information?
 
Under what circumstances are you billing G0202 and G0206 together? G0202 is for a screening mammogram, and if you add a 52 modifier, it is implying that only one breast was imaged. G0206 is a diagnostic unilateral mammogram. If they are performed the same day, there is a separate modifier which indicates that it was a screening mammogram converted to a diagnostic mammogram.

Patricia Murrin, CPC, RCC
 
Patient is due for yearly screening and a follow up on the other breast. In the past we would bill G0202 52, G0206 611.72 V67.59. We would be paid 50% of the G0202 and full contract price for the G0206. This year the G0202 is being denied for bundling. No help when contacting Medicare. I cannot find any rules that show a change.
 
In 2015, there is a CCI edit between CPT G0202 & G0206 so if you have proper documentation, then modifier 59 can be added to column 2 code. also check GG modifier as you are billing G0202 and G0206 on same day.
 
Coding Data Analyst CPC

It would be inappropriate to do a screening on one breast and a diagnostic on the other. If a patient presents with symptoms/problems in one breast, she would not qualify for a screening.
If a bilateral screening and a diagnostic mammogram are done on the same day, modifier GG would be appended to the diagnostic, with V76.12 or V76.11 and a secondary code, the reason for converting to a diagnostic, 611.72, 793.89 etc.
If a screening mammogram is done the first diagnosis code has to be V76.12 or V76.11.
:)
 
Coding Data Analyst CPC

Since January because of the new CCI edit, you must add modifier 59 the the screening exam and GG to the diagnostic.
 
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