Ob-Gyn Coding Alert

When reporting mammograms, determining whether to bill for a screening or diagnostic service depends on why the physician ordered it. So ask yourself "Why?" to pick the proper code.

Although diagnostic (76090, Mammography; unilateral; and 76091, bilateral) and screening (76092, Screening mammography, bilateral [two view film study of each breast]) mammographies are similar in how the physician performs them, they are very different in the eyes of payers. A physician performs a screening as a routine procedure to detect breast cancer early. On the other hand, the ob-gyn will use the diagnostic service when signs or symptoms (such as nipple discharge, a mass, tenderness or skin changes) are present to indicate that cancer or another breast disorder may already exist.

When a woman presents for her annual screening, you should use 76092. This code includes imaging both breasts. Consequently, you should note that you should not report it twice or with modifier -50 (Bilateral procedure) for a single session. If the ob-gyn reduces the service to view only one breast, you should contact your carrier before filing the claim. Some payers maintain you should not append 76092 with modifier -52 (Reduced services) either.

If you use modifier -52 with 76092, "you may want to use modifier -RT (Right side) or -LT (Left side) for further clarification," says Joyce Dansby, CPC, a claims manager with A&R Management Services in Tampa, Fla. And be sure to adjust your fee to reflect the reduced services, she adds.

You should include the report when submitting the claim with modifier -52 to more clearly show the payer why you scanned only one breast, Dansby says.

Reimbursement for screenings is determined by the number of months between the mammograms. For example, Medicare allows a woman in her 40s one screening every 12 months. Medicare also will cover a one-time initial, or baseline, mammogram for women 35-39 years of age, says Jaime Darling, CPC, a certified coder with Graybill Medical Group in Southern California.

CMS defines women with a family history of breast cancer as being at high risk for developing breast cancer, but this alone is not enough for you automatically to report a mammography as diagnostic. When using 76090-76091, you must list a specific diagnosis to prove the procedure's medical necessity, which may include the following: