Oncology & Hematology Coding Alert

If you're not sure whether to use 76092 or 76090 when a patient has a screeningturned-diagnostic mammogram, you're risking unnecessary denials. But a few simple pointers offered by coding experts should clear up any confusion and boost your reimbursement for these transitional studies.

If a woman has a family history of breast cancer (V16.3), that alone doesn't mean you can classify the mammogram as "diagnostic." Although you may think mammogram screenings and diagnostic mammograms are quite similar, payers see them differently, says Carolyn M. Davis, CMA, CPC, CCP, CCS-P, CPHT, TMC, billing supervisor for Oncology Hematology West in Papillion, Neb., and a professional coding and continuing-education instructor at Iowa Western Community College.

Medicare and private carriers consider a screening mammogram, 76092 (Screening mammography, bilateral [two view film study of each breast]), a routine procedure performed for asymptomatic patients to detect breast cancer. For example, a 40-yea rold woman visits her primary-care physician for her annual exam.

On the other hand, carriers recognize diagnostic mammograms, 76090 (Mammography; unilateral) and 76091 (... bilateral), when a woman presents to your oncologist with signs or symptoms that signify breast neoplasm, such as nipple discharge (611.79), mass (611.72) and mastodynia (611.71). And, Medicare carriers like AdminaStar Federal in Indianapolis don't require a year waiting period when reporting diagnostic mammograms, as long as you support your claim with the proper conditions, such as 611.72 and 611.79.

Use G0202 for Digital Mammograms If your oncologist owns and operates digital mammogram imaging equipment, you should use the temporary HCPCS codes, not 76090-76092. But make sure your practice uses this technology, which allows the physician to magnify and optimize different parts of the breast tissue, before you submit these codes, or your carrier will deny your claim. Filing the HCPCS codes signifies that your practice owns the equipment.

When Medicare patients have screening mammography performed with digital imaging, report G0202 (Screening mammography, producing direct digital image, bilateral, all views). For bilateral diagnostic mammograms performed with digital imaging, use G0204 (Diagnostic mammography, producing direct digital image, bilateral, all views). You should code unilateral diagnostic mammograms with digital imaging as G0206 (Diagnostic mammography, producing direct digital image, unilateral, all views).

Also, you may assign G0236 (Digitization of film radiographic images with computer analysis for lesion detection, or computer analysis of digital mammogram for lesion detection, and further physician review for interpretation, diagnostic mammography [list separately in addition to code for primary procedure]) along with G0204 or G0206, says Linda L. Lively, MHA, CCS-P, RCC, CHBME, founder and CEO of American Medical Accounting and Consulting in Marietta, Ga.
 
CPT includes add-on code +76085 (Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, mammography [list separately in addition to code for primary procedure]) to define digitization for those payers that do not accept the HCPCS G codes, Lively says. For example, if you need to code a digital mammogram for a private carrier that normally denies G codes, you should submit 76085 with the appropriate HCPCS code.
 
Although CPT's definition indicates that you can report 76085 with 76091 and 76092, Lively says that CMS offers a different definition: "Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, screening mammography."
 
This different definition means that Medicare will allow you to bill 76085 along with primary-service code G0202 and 76092. But you can't report the add-on code alone, Lively says.
 
Remember that you can bill for only one screening mammogram, either 76092 or G0202, in a calendar year. Therefore, advise your oncologist not to submit claims that reflect both a screening mammography (76092) and a digital mammography (G0202), because you will not be able to report either code for another year, Lively says.

Know How to Justify an Implant Diagnosis

Women with breast implants present new challenges for oncology coders: Because implants put women at a higher risk for cancer, can you assign breast implants as a justifiable condition for diagnostic mammograms?
 
No, you can't automatically assume a carrier will cover a diagnostic mammogram just because the patient has implants. Also, you can't use V76.11 (Screening mammogram for high-risk patient) to support a diagnostic mammogram for a woman with breast implants. Medicare finds that code too vague, coding experts say. In other words, never use implants alone as justification for a diagnostic mammogram, especially for a Medicare patient, coding experts say.
 
If, however, a physician inserted the breast implants after a mastectomy (19200) for breast cancer, you could use the implants as medical necessity. For Medicare, a patient's personal history of cancer typically substantiates a diagnostic mammogram. Be sure your carrier doesn't restrict the time between the cancer treatment and any recurring symptoms that your patient's case doesn't meet, such as five years between treatment and recurrence.