Oncology & Hematology Coding Alert
A Coding Challenge You Cant Afford to Overlook
A fine line separates screening and diagnostic mammogram tests, and you had better not cross it. Though similar procedures, they are very different in the eyes of payers even for mammograms on women who have breast implants. When you're coding, you should separate screening and diagnostic mammograms in the same way your payer will separate them. Screening mammograms, 76092 (Screening mammography, bilateral [two-view film study of each breast]) are routine procedures performed to detect breast cancer early in asymptomatic patients. The physician doesn't usually meet face-to-face with the patient receiving a screening mammography, says Mary Session, CPC, billing supervisor for Associated Billing Services in Phoenix. The technician performs the mammogram, and the physician doesn't usually read the film until the end of the day, she says. Diagnostic mammograms, 76090 (Mammography; unilateral) and 76091 (... bilateral), on the other hand, are procedures performed for patients with signs or symptoms of breast disease nipple discharge, mass development, tenderness or skin changes. Combined with diagnosis codes that support medical necessity, diagnostic mammography codes have no restrictions on frequency of billing, Session says. You must learn how to distinguish between the two types. Just because a woman has a family history of breast cancer, you can't classify the mammogram as "diagnostic," says Stacy J. Hardy, CPC, coding specialist with Sierra Vista Diagnostics in Arizona. To brush up on the basics for differentiating screening and diagnostic mammograms, look for "Get Paid What You Deserve: Don't Confuse Screenings With Diagnostic Mammograms" in the June 2002 Oncology Coding Alert. Read below to pump up payment for one particular mammogram case tests on patients with breast implants. Don't Make Assumptions About Women With Implants One of the trickier mammogram cases to code and one that's becoming more and more prevalent is the mammogram for women with breast implants. Don't use the presence of implants alone as a justification for the diagnostic mammography code, especially for a Medicare patient, Hardy advises coders. According to CMS, patients with breast implants do not automatically qualify for diagnostic mammograms. If there are extra films, don't automatically select a code other than 76092. Certain screening mammograms, including those for patients with breast implants, may require more than the standard two-view exposure of each breast for screening mammograms, CMS states. If this is the case, Medicare instructs coders to report ICD-9 code 996.54 (Mechanical complications due to breast prosthesis) to substantiate taking the extra films. You should still report the screening mammography code. You're dealing with another ball game, however, if the patient had implants placed after a mastectomy for breast cancer, Hardy says. A personal history of cancer typically justifies reporting a diagnostic mammogram. Just be sure your carrier doesn't have restrictions on the length of time between the cancer treatment and recurring symptoms that your patient's case does not meet. Please Payers With Covered Diagnosis Codes Don't distinguish a screening from a diagnostic mammography and then blow it by linking the procedure code to a noncovered diagnosis code. Diagnostic codes for screening mammography: Match the procedure code for a bilateral screening mammogram, 76092 or G0202 (Screening mammography, producing direct digital image, bilateral, all views), on a low-risk patient to the diagnostic code V76.12 (Other screening mammogram). Diagnostic codes for diagnostic mammography: Choosing ICD-9 codes for diagnostic mammograms is not as easy because covered diagnosis codes vary from carrier to carrier. Reliable ICD-9 codes that most payers cover for 76090 (Mammography; unilateral), 76091 ( bilateral), G0204 (Diagnostic mammography, producing direct digital image, bilateral, all views) and G0206 (Diagnostic mammography, producing direct digital image, unilateral, all views) include but are not limited to: Many local medical review policies also cover diagnostic mammograms matched with diagnoses codes 175.0 (Malignant neoplasm of male breast; nipple and areola), 175.9 (... other and unspecified sites of male breast) and 233.0 (Carcinoma in situ of breast and genitourinary system; breast). Coder to Coder Don't underestimate Medicare's frequency regulations on screening mammograms, says Stacy J. Hardy, CPC, a coding specialist with Sierra Vista Diagnostics in Arizona. "Screenings are only covered a year and a day apart," she says. If a patient wants to come in early for convenience's sake, for example, to avoid travel conflicts, Medicare won't cover the early screening. So you should ask the patient to sign an advance beneficiary notice (ABN), which makes the patient responsible for paying the bill if Medicare doesn't cover it.
That means the same breast cancer screening guidelines that apply to women who don't have implants, apply to those who do.
For a high-risk patient, link the appropriate screening mammography procedure code to V76.11 (Screening mammogram for high-risk patient). You should account for any additional pertinent information, if applicable, by reporting additional ICD-9 V codes, for example V10.3 (Personal history of malignant neoplasm; breast), V15.89 (Other specified personal history presenting hazards to health; other) or V16.3 (Family history of malignant neoplasm; breast).
If your office doesn't have access to a patient's films because they are at another facility, don't assume that enough time has passed to perform another screening mammogram that Medicare will cover. If you perform a screening mammogram and then later find out once you have received the records that a year and one day (366 days) has not passed since the last screening, chances are you are going to have trouble getting paid from anyone, especially if the patient didn't sign an ABN.
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