Oncology & Hematology Coding Alert

Question: How can I determine whether a mammogram should be coded as screening (76092) or diagnostic (76090-76091)? Can my oncologist get paid for two mammograms on the same patient in a six-month period? Also, how should I code a mammogram for a patient in remission?

Arkansas Subscriber

Answer: Although mammography screening appears similar to its diagnostic counterpart, carriers view these tests as two different procedures. A screening is a routine procedure performed to detect breast cancer (174.9, Malignant neoplasm of female breast; unspecified) early and includes an oncologist's interpretation of the results. Medicare reimburses diagnostic mammograms when the patient presents signs or symptoms proving medical necessity. So in your documentation, list specific diagnoses, such as:
 
 breast changes that persist, such as a lump (611.72), dimpling (611.8), skin irritation (611.9), nipple discharge or bleeding (611.79), and breast pain (611.71, Mastodynia)
   follow-up of abnormal mammogram
   conversion of a screening mammogram to a diagnostic mammogram.  When a woman presents for her annual screening, report 76092 (Screening mammography, bilateral [two view film study of each breast]). The number of months between the first and the last mammogram dictate the reimbursement. For example, Medicare allows a 40-year-old woman one annual screening. Also, because the procedure code encompasses imaging both breasts, don't code 76092 twice or report with modifier -50 (Bilateral procedure). If the oncologist reduced the service to a unilateral view, check with your local carriers regarding how to file that claim. Some Medicare carriers say you shouldn't append modifier -52 (Reduced services) to 76092.
 
Carriers might reimburse an oncologist if he has to perform another diagnostic mammogram on the same patient within six months of the last one, as long as he matches the diagnosis code with the reason the patient came in. To receive payment, Medicare requires that you list one of the following codes: V10.3 (Personal history of malignant neoplasm of breast), V15.89 ( presenting hazards to health, other specified, other), 174.0-174.9 (Malignant neoplasm of female breast), 175.0-175.9 ( male breast), 238.3 (Neoplasm of uncertain behavior of breast), 239.3 ( 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 (Unspecified breast disorder).