Ob-Gyn Coding Alert

Test your coding abilities. Review the following clinical circumstances to determine if they meet the screening or diagnostic mammogram parameters. Then look at the answer to see if our coding experts agree.

Scenario 1: A 40-year-old woman presents to the ob-gyn after she notices a lump in her breast six months after her last screening.

Answer1: Diagnostic. Other than symptoms of cancer, there is no cancer diagnosis code available to show the mammogram is more than a screening. But Medicare and other payers allow reimbursement for diagnostic mammograms based on specific symptoms that indicate the potential for breast cancer. In this case, you should report 76090 (Mammography; unilateral) linked to the diagnosis code 611.72 (Lump or mass in breast).

Scenario 2: A patient whose breast cancer is in remission presents for a follow-up mammogram.

Answer 2: Diagnostic. When a patient whose cancer is in remission comes in for a follow-up diagnostic mammogram, you should report V10.3 (Personal history of breast cancer) as the diagnosis. 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 regarding which test to order rests with the attending physician.

Scenario 3: A 52-year-old woman presents for a routine screening that reveals a mass. The ob-gyn orders a diagnostic procedure later that day.

Answer 3: Diagnostic. If the screening leads to a diagnostic mammogram during the same session, you should report only the diagnostic procedure because the screening is bundled. Medicare allows for additional mammography views when a screening shows a potential problem.

To report a screening converted to a diagnostic, you should use 76090 or 76091 ( bilateral) appended with modifier -GH (Diagnostic mammogram converted from screening mammogram on same day). Be sure to link the code with V76.12 (Other screening mammogram). The presence of a diagnosis such as 611.72 should indicate to you that the ob-gyn performed the second mammogram after finding an abnormality during an earlier screening.