Outpatient Facility Coding Alert

Tip: Extra views don’t automatically change your coding.

Facilities sometimes have policies stating that the staff should automatically get extra views when a patient with a history of breast cancer comes for a mammogram. The question for coders is: Do the extra views mean the exam is diagnostic even if the patient presents for a screening?

The short answer: Routine performance of extra views for patients with a history of breast cancer is not sufficient to support coding a diagnostic mammogram (77055, Mammography; unilateral or 77056, … bilateral)  rather than a screening (77057, Screening mammography, bilateral [2-view film study of each breast]).

Distinguish Your Definitions

To ensure proper coding, review the payer’s definitions of screening and diagnostic mammography. Also review the rules for when the physician may convert a screening exam to diagnostic without an additional physician order, advises Sarah Goodman, MBA, CHCAF, CPC-H, CCP, FCS, president of the consulting firm SLG, Inc., in Raleigh, N.C.

Diagnostic: For Medicare, “diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease,” according to the Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.4, Mammograms (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_Part4.pdf).

Note that although Medicare covers diagnostic mammography for patients with a history of breast cancer, not every mammogram for those patients will be diagnostic. As an example, NGS Medicare states that “once clinical and mammographic stability has been established, the routine use of diagnostic mammography over screening mammography is not warranted” (LCD L26890, http://apps.ngsmedicare.com/lcd/LCD_L26890.htm).

Screening: “A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease,” the mammography NCD states.

Order requirements: Diagnostic exams require a physician’s order. Medicare will cover screening mammograms even without a physician order for women who meet age and frequency requirements, according to the Medicare Claims Processing Manual (MCPM), Chapter 18, Section 20.A (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf).

If the screening reveals a potential problem, Medicare allows radiologists to order additional mammography views “while a beneficiary is still at the facility for the screening exam,” states MCPM, Chapter 18, Section 20.6.A. You should report both screening and diagnostic codes. Append GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) to the diagnostic code. Medicare will pay for both the screening and diagnostic exams.

Diagnosis: For the screening exams for patients with a history of breast cancer, report V76.11 (Screening mammogram for high-risk patient) and V10.3 (Personal history of malignant neoplasm of breast). Under ICD-10, the crosswalked codes are Z12.31 (Encounter for screening mammogram for malignant neoplasm of breast) and Z85.3 (Personal history of malignant neoplasm of breast).