Oncology & Hematology Coding Alert

Question: If a provider performs an evaluation and management (E/M) service and orders lab work to screen for breast cancer, should I attach the screening codes to the E/M even if the screens weren’t performed on the same day as the office visit?

AAPC Forum Participant

Answer: Whether or not you attach Z12.39 (Encounter for other screening for malignant neoplasm of breast) to a preventive E/M service documented with 99381-99396 (Initial/periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new/ established patient …) will depend on whether your provider performed the screening as a part of the E/M service.

You should only use a screening code if the patient is asymptomatic, as ICD-10-CM guideline I.C.21.c.5 explains that a screening is performed for the sake of early detection in individuals. If the patient presents and your provider detects specific signs and symptoms of breast cancer, then the breast examination is regarded as diagnostic, not a screen, and you would use a breast neoplasm code, a breast neoplasm history code, Z08 (Encounter for follow-up examination after completed treatment for malignant neoplasm) or a code from R92.- (Abnormal and inconclusive findings on diagnostic imaging of breast) as appropriate.