Oncology & Hematology Coding Alert
Dont Confuse Screenings With Diagnostic Mammograms
Recently, U.S. Health and Human Services Secretary Tommy Thompson reaffirmed the importance of mammograms for women 40 years of age and older. Although the announcement bodes well for expanding coverage of mammogram screenings among payers who limit coverage to women who are age 50 and older, it will have no effect on diagnostic mammograms. Oncology practices must still provide proper ICD-9 codes to avoid the diagnostic procedure from being mistaken as a noncovered screening. Focus on Symptoms Although age and frequency determine reimbursement for screenings, payment for diagnostic mammography depends on diagnosis codes that support its medical necessity (see sidebar on page 42), says Paula Stinecipher, CPC, co-founder and president of AlphaQuest, an Atlanta-based coding and consulting firm.
Aside from 76090-76091, Medicare recognizes three temporary codes for mammography procedures that produce digital imagery: Although women with a family history of breast cancer are at high risk, their history alone is not enough to support medical necessity for a diagnostic mammography. Instead, payers will interpret a mammogram performed within one year of the last screening as medically unnecessary. However, a woman who seeks care after discovering a breast lump (611.72) will require a diagnostic mammogram regardless of when her last screening took place. Scenarios Distinguish Diagnostic From Screening The following scenarios illustrate how to 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 to show that 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 would be 611.72 (Lump or mass in breast) and the procedure code would be 76090 (Mammography; unilateral). 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. The oncologist orders a diagnostic procedure the same day. If the screening precedes and leads to diagnostic mammography during one session, you should code only for the diagnostic mammography. Follow-up diagnostic mammogram for patient in remission. Patients who have been treated successfully for cancer are never really considered cancer-free. For that reason diagnostic mammograms are an integral component of managing a patient's after-care. This means mammograms may occur with greater frequency. To prove medical necessity you should list 174.9 (Malignant neoplasm of female breast, unspecified), even though the cancer is in remission.
Diagnostic mammograms are more common than screenings for oncologists because they usually see patients if there are symptoms. Failure to distinguish a diagnostic mammography (76090-76091) from a screening could lead to denials, says Nancy Giacomozzi, manager of P.K. Administrative Services, a medical billing company in Lakewood, Colo.
In general, Medicare pays for diagnostic mammograms based on the following:
To report a diagnostic mammogram converted from a screening mammogram, you should use 76090 or 76091 ( bilateral) and append modifier -GH (Diagnostic mammogram converted from screening mammogram on same day) to the appropriate code. The diagnosis code is V76.12 (Other screening mammogram). 
Oncology & Hematology Coding Alert
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