Internal Medicine Coding Alert

Coders, you are your practice's best line of defense against submitting a claim or an order for a screening mammogram linked to a diagnosis code that merits a diagnostic mammogram.

To be able to code screening-turned-diagnostic mammograms without digital imaging, you must first be able to identify and differentiate between the two types. "Even though internists don't normally provide [mammogram] services, they frequently order them, and it is important to understand the coding nuances" so the orders can be written correctly, says Kathy Pride, CPC, CCS-P, HIM applications specialist with QuadraMed, a national healthcare information technology and consulting firm based in San Rafael, Calif.

For example, just because a woman has a family history of breast cancer doesn't mean you can automatically order a diagnostic mammogram, says Stacy J. Hardy, CPC, coding specialist with Sierra Vista Diagnostics in Arizona. To order a diagnostic mammogram, the physician has to list a diagnosis code that is covered for and substantiates a diagnostic mammogram.

Although mammogram screenings and diagnostic mammograms are similar procedures, they are very different in the eyes of payers.

A screening mammogram, 76092 (Screening mammography, bilateral [two view film study of each breast]), is considered a routine procedure performed for asymptomatic patients for the purpose of early detection of breast cancer.

On the other hand, diagnostic mammograms, 76090 (Mammography; unilateral) and 76091 ( bilateral), are mammograms performed for a patient who presents with signs or symptoms of breast disease, e.g., nipple discharge, a mass, tenderness or skin changes. And with diagnosis codes that support medical necessity for the diagnostic mammography, there are no restrictions on its frequency of billing (see Please Payers With Covered Mammogram Diagnosis Codes).

Don't Make Assumptions About Women With Implants

One of the trickier cases to identify, and one that is becoming more and more prevalent, is whether mammograms for women with breast implants should be considered screening or diagnostic.

The Centers for Medicare and Medicaid Services (CMS) asserts that patients with breast implants do not automatically qualify for diagnostic mammograms, which means the same breast cancer screening guidelines apply to women with breast implants.

CMS does, however, clarify that certain screening mammograms, e.g., in the case of a patient with breast implants, may require more than the standard two-view exposure of each breast that is standard for screening mammograms. If this is the case, Medicare instructs coders to report ICD-9 code 996.54 (Mechanical complications due to breast prosthesis) to substantiate taking the extra films.

If the implants were placed after a mastectomy for breast cancer, Hardy says, it's another ball game. The personal history of cancer is typically enough to substantiate reporting the diagnostic mammogram; just be sure your carrier doesn't have restrictions on the length of time between the cancer treatment and any recurring symptoms that your patient's case does not meet.

Take the Quiz

Test your ability to determine whether these clinical circumstances meet the requirements for the physician to submit an order for a diagnostic or screening mammogram:

Scenario 1: A 40-year-old woman notices a lump in her breast six months after her last screening. The diagnosis code assigned is 611.72 (Signs and symptoms in breast, lump or mass in breast).

Answer 1: Diagnostic. Other than symptoms of cancer, there is no diagnosis code available to substantiate medical necessity for a diagnostic mammogram. However, Medicare and other payers will reimburse for diagnostic mammograms based on specific symptoms that indicate the potential for breast cancer, including 611.72. Because the patient presented with one mass limited to one breast, 76090 is the proper CPT code to represent the procedure when the physician orders a unilateral diagnostic mammogram.

Scenario 2: A patient whose cancer is in remission presents for a diagnostic mammogram.

Answer 2: Diagnostic. When a patient whose cancer is in remission comes in for a follow-up diagnostic mammogram, the correct diagnosis code is V10.3 (Personal history of breast cancer). Either screening or diagnostic mammograms are considered an integral component of managing aftercare for patients who have been successfully treated for cancer, and the decision on which test to order rests with the attending physician.