Oncology & Hematology Coding Alert

Determining whether a mammogram should be coded as screening or diagnostic depends on why the patient had the procedure, says Stacey Hall, RHIT, CPC, CCSP, director of coding with Medical Management Professionals in Chattanooga, Tenn. This distinction will help coders educate payers and avoid confusion.

Screening vs. Diagnostic

While women with a family history of breast cancer are at higher risk, this alone is not enough for oncology practices to justify the procedure as diagnostic. Payers will interpret mammograms performed within one year of each other as medically unnecessary.

Diagnostic mammograms, 76090-76091, are reimbursed when the beneficiary presents signs or symptoms proving medical necessity, Hall explains.

Although a mammography screening, 76092 (screening mammography, bilateral [two view film study of each breast]), is similar to its diagnostic counterpart, they are very different in the eyes of payers. A screening is a routine procedure performed for the purpose of early detection of breast cancer, and includes a physicians interpretation of the results.

Note: Federal guidelines offer the following rules for the frequency of mammogram screenings: 35-39 only one screening; 40 and above annual screenings are allowed. Eleven full months must elapse following the month of the patients last one.

Screening

When a woman presents for her annual screening, 76092 should be used. The procedure code encompasses imaging of both breasts; therefore, it is important to note that it should not be coded twice or reported with modifier -50 (bilateral procedure). If the service was reduced to a unilateral view, some Medicare carriers say 76092 should not be appended with modifier -52 (reduced services). But, Hall suggests that coders check with their local Medicare carriers before filing a claim.

Reimbursement for screenings is dictated by the number of months between the first and the last mammogram. For example, Medicare allows a woman in her 40s one screening every 12 months.

Diagnostic

When using codes 76090-76091, specific diagnoses must be listed to prove medical necessity. A diagnostic mammography is indicated in the presence of symptoms or signs of breast disease, such as nipple discharge or bleeding, presence of a mass, skin changes, tenderness or other abnormalities.

If, however, a diagnostic is required six months after the last one, the practice can still get paid for it if a reason is demonstrated. You really have to match your diagnosis code with the reason the patient came in, says Barbara Levy, MD, FACOG, FACS, a private practitioner in Seattle and a member of the nomenclature committee of the American Academy of Obstetricians and Gynecologists (ACOG).

In order to do so, Medicare requires at least one of the following be listed:

V10.3 personal history of malignant neoplasm of breast;

V15.89 personal history presenting hazards to health, other specified, other;

174-174.9 malignant neoplasm of female breast;

175-175.9 malignant neoplasm of male breast;

238.3 neoplasm of uncertain behavior of breast;

239.3 neoplasms of breast, unspecified nature;

610.0-610.9 benign mammary dysplasias;

611.71-611.8 signs and symptoms in breast; breast disorders, other specified;

611.9 breast disorder unspecified.

Scenarios Help to Clarify Coding

The following examples distinguish a diagnostic mammography from a screening:

Diagnostic procedure performed before next covered screening. A 40-year-old woman notices a lump in her breast six months after her last screening. Other than symptoms of cancer, there is no cancer diagnosis code available to show the procedure 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. The proper diagnosis code is 611.72 (lump or mass in breast), and the procedure code is 76090.

Routine screening shows abnormality and requires a diagnostic mammogram on the same day. A 52-year-old woman presents for a routine screening that reveals a mass. A diagnostic procedure is ordered for later that day. If the screening leads to a diagnostic in the same session, only the diagnostic should be coded. The screening is bundled into this procedure.

Medicare allows for additional mammography views when a screening shows a potential problem. If the interpretation results in additional films, the mammo-graphy is no longer considered a screening and only the diagnostic x-ray(s) should be billed. The original screening test should not be billed because it does not meet the requirements for age, frequency or payment.

To bill a diagnostic converted from a screening, practices should use 76090 or 76091 appended with modifier -GH (diagnostic mammogram converted from screening mammogram on same day). The proper diagnosis code is V76.12 (other screening mammogram), Hall says. The presence of a code such as 611.72 should indicate to the coder that the second mammogram was taken after an abnormality was found during an earlier screening.

Followup diagnostic mammogram for patient whose cancer is in remission. Patients who have been successfully treated for cancer are never really considered cancer-free. For this reason, diagnostic mammograms are considered an integral component of managing after care and may occur more often. To prove medical necessity, 174.9 should be listed, even though the cancer may be in remission.

Note: Although no documentation other than diagnosis codes has to be submitted, the patients medical record should document patient symptoms and signs and the appropriate condition or diagnosis to substantiate the medical necessity for a diagnostic mammography.