Dermatology Coding Alert

The contractor instructs you to start using modifier 52 in some cases

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

Leading the way: In August, Empire Medicare Services issued an updated local coverage determination (LCD) that clarified how billers should claim mammography services, including which diagnosis codes to assign and when you need to use a modifier. Make sure you're up-to-date on Empire's guidelines to guarantee you don't see denials.

You can review the LCD at www.empiremedicare.com/news/njnews06/081506scr.htm.

Bill for Both Screening and Diagnostic Services

The latest LCD informs billers that Empire will reimburse for both the screening mammography and the diagnostic mammography when a radiologist's interpretation of the screening mammogram leads to a need for additional views.

How it works: 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, Empire says. Empire will pay you for both the screening and diagnostic mammograms.

"This part of the policy has actually been in place for a number of years," says Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga. "National Medicare policy allows payment for both a screening mammo and a diagnostic exam when the diagnostic exam is ordered by the radiologist on the basis of abnormal findings on the screening exam. This is an exception to the rule that requires diagnostic tests to be ordered by the treating physician. Most non-Medicare payers also follow this policy."

Diagnosis changes: In the LCD, Empire instructs billers to use particular diagnosis codes on these sorts of claims.

Be sure to bill the screening mammography with ICD-9 diagnosis code V76.11 (Screening mammogram for high-risk patient) or V76.12 (Other screening mammogram). For the diagnostic mammogram, you should use one of the ICD-9 codes that Empire lists in its LCD for diagnostic mammography, or screening mammography that converts to diagnostic.

The change is that Empire removed V76.12 from the acceptable code list for the diagnostic procedure. Empire says that "this ICD-9-CM code is only appropriate for use with a screening mammography."

All on one: You should bill for the screening and diagnostic mammograms on the same claim, Empire says. You should append 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.

How to tell: If you're trying to determine whether you need to bill both a screening and a diagnostic mammogram, look to the physician's documentation.

Append Modifier 52 for Unilateral Screening

You may wonder if a unilateral mammogram can ever be billed as a screening mammogram, such as when the doctor is only checking one breast because the patient already had a mastectomy or problems with one breast in particular.

Modifier requirements: If you're billing Empire for the screening mammography, use codes 76092 (Screening mammography, bilateral [two view film study of each breast]) or G0202 (Screening mammography, producing direct digital image, bilateral, all views) and +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) regardless of whether the physician performs the procedure on one or both sides.

Append modifier 52 (Reduced services) for unilateral screening mastectomies. Empire will pay for this service at 75 percent of the payment for a bilateral mammogram.

"The most interesting point in the Empire article is the instruction to use modifier 52 on the code for computer-assisted detection (76083) when a unilateral screening mammo is performed," Miller says. "I have not seen that instruction from other payers, although it is standard practice to use modifier 52 on the mammogram code (76092) when only one breast is screened."

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