Oncology & Hematology Coding Alert

Test your ability to determine whether a screening or diagnostic mammogram should be coded in these clinical scenarios, and then read the answers  provided by coding experts.
 
Scenario 1: A 40-year-old woman notices a lump in her breast six months after her last screening. Your oncologist assigns diagnosis code 611.72 (Signs and symptoms in breast; lump or mass in breast).
 
Scenario 2: A 52-year-old woman presents for a routine screening that reveals a mass. Your oncologist orders a diagnostic procedure for later that day.
 
Scenario 3: A patient with cancer in remission presents for a diagnostic mammogram.






Answer 1: Diagnostic. Other than cancer symptoms, CMS offers no diagnosis code to substantiate medical necessity for a diagnostic mammogram. But Medicare and other payers will reimburse for diagnostic mammograms based on specific symptoms that indicate the potential for breast cancer, including 611.72. Because the patient presented with one mass limited to one breast, you should use 76090 (Mammography; unilateral) for the service when your oncologist orders a unilateral diagnostic mammogram.
 
Answer 2: Screening and diagnostic. When a routine screening shows an abnormality and requires a diagnostic mammogram on the same day, you should report both the code for the screening mammogram (76092, Screening mammography, bilateral [two view film study of each breast]) and the code for the diagnostic mammogram (76090).
 
Most Medicare carriers advise oncology coders to sequence the screening code, 76092, as the primary procedure performed and link it to the appropriate V code, most likely V76.12 (Special screening for malignant neoplasms; breast, other screening mammogram).
 
List the diagnostic mammogram, 76090 (or 76091 if your physician orders a bilateral study), second and link it to either the diagnosis code 611.72 or a more specific exam finding. You should report the unilateral diagnostic mammogram code because tests found no multiple masses. If Medicare covers the patient, append modifier -GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) to the diagnostic mammogram code.
 
Answer 3: Diagnostic. When a patient with cancer in remission comes in for a follow-up diagnostic mammogram, use V10.3 (Personal history of breast cancer). Medicare considers either screening or diagnostic mammograms as an integral component of managing aftercare for patients in remission.