Ob-Gyn Coding Alert

Find out whether this payer approves unilateral screenings

 

One carrier has clarified the coding issues around screening mammograms converted to diagnostic, as well as reporting troublesome unilateral screening mammograms -- and other payers may follow.
     
The issue: If a patient comes in for a screening mammogram and the physician sees something that requires further study, you can bill for extra views using diagnostic codes, says Empire, the Medicare Part B carrier for New Jersey and New York. Empire will pay for both the screening and diagnostic mammograms.

 

Here's What You Should Do

 

You should support 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), Empire says.

     
For the diagnostic mammogram, you should use one of the ICD-9 codes that Empire lists in its local coverage determination (LCD) for diagnostic mammography, or screening mammography that converts to diagnostic.

     
Watch out: You can only report what your ob-gyn documents. If the patient's diagnosis does not fit into the LCD list of ICD-9 codes, you cannot tweak the claim to fit.

      Also, Empire instructs you to bill for the screening and diagnostic mammograms on the same claim, the carrier says.
     
Don't forget: 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.
     
Tip: 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 technician will mention it somewhere in his dictated mammogram report.

 

Tackle This Unilateral Mammogram Problem

 

Many coders have questioned whether you can ever bill a unilateral mammogram as a screening mammogram. Chances are, the ob-gyn 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 77057 (Screening mammography, bilateral [two-view film study of each breast]) or G0202 (Screening mammography, producing direct digital image, bilateral, all views) combined with +77052 (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).
           
Essential: You should use modifier 52 (Reduced services) for unilateral screening mammograms because mammography is a bilateral procedure, and the ob-gyn is examining only one breast in this case. 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 ob-gyn 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, read -Screening Mammography, Diagnostic Mammo-graphy, and Screening Mammography That Converts to Diagnostic Mammography- (www.empiremedicare.com/news/nynews06/081506scr.htm) and -Breast Imaging: Mammography/Breast Echography (Sonography)/Breast MRI Ductography- (www.empiremedicare.com/newypolicy/policy/l3500_final_guideline.htm).
           
Always: Check your payer's mammogram coding rules before you send in your claim.