Radiology Coding Alert

Watch for procedures where mammography is inclusive.

When reporting mammograms, you can make your life easy by understanding why your radiologist did the procedure and what was the result of the investigation. Besides diagnosis and screening, radiologists can use mammography to guide additional procedures. Check out how and when you can most appropriately report the mammography codes. 

Tip 1: Confirm Diagnostic vs. Screening

For mammography reporting, you should first determine whether your physician did a diagnostic or screening procedure. 

Diagnostic: When reporting diagnostic mammography, you pick up the right code depending upon whether your physician did the procedure on one or both sides. You should accordingly choose from 77055 (Mammography; unilateral) and 77056 (Mammography; bilateral). 

Screening: For screening mammography, you turn to code 77057 (Screening mammography, bilateral [2-view film study of each breast]).

What is screening mammography? Screening mammography is a radiologic procedure provided to an asymptomatic woman for the purpose of early detection of breast cancer and includes a physician’s interpretation of the results of the procedure. “A screening mammogram is performed on women without any signs or symptoms of breast cancer,” says Christy Hembree, CPC, Team Leader, Summit Radiology Services, Cartersville, GA. “It is a type of is a type of radiography used on the breasts as a preventive measure of asymptomatic cancer.” 

Tip 2: Ask, How is Screening Mammography Different? 

Diagnostic and screening mammographies are different procedures. Unlike diagnostic mammographies, there needn’t be signs, symptoms, or history of breast disease in order for the screening exam to be covered. A doctor’s prescription or referral is not necessary for the procedure to be covered. “Diagnostic mammography is typically not a preventive service where a screening mammogram typically is,” Hembree says. “Diagnostic mammography is usually used to evaluate a patient presenting with signs or symptoms of the breast, changes found during screening mammography, or when screening mammography is difficult to obtain because of special circumstances, such as the presence of breast implants.”

According to Medicare, patients who meet age and frequency requirements needn’t have an order from the physician to get a screening exam.

For billing a diagnostic mammogram, you should ensure you have: 

• a physician order for the diagnostic service, 
• signs and symptoms supporting medical necessity, or 
• a personal history or other factors based on which your physician decides a diagnostic service.

Note: You should not use number of views as a criterion to distinguish screening vs. diagnostic. “Screening mammography essentially consists of minimum of two views (craniocaudal [CC] and mediolateral oblique [MLO]). Additional views may be needed for a screening mammogram, and this does not automatically change a screening mammogram to a diagnostic one,” says Stacie L. Buck, RHIA, CCS-P, RCC, CIC, President and Senior Consultant, RadRx, Stuart, FL. A diagnostic mammogram typically will consist of CC and MLO views, plus additional views such as latero-medial (LM) or medio-lateral (ML).

Tip 3: Here’s How to Report both for a Single Day of Service

Your physician may perform a screening as well as a diagnostic mammogram on the same day. This may happen when a patient presents for a screening mammogram, and your radiologist detects a suspicious abnormality. This may necessitate a separate unilateral or bilateral diagnostic mammogram on the same date. 

In this case, you should report both services and append modifier GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) to the diagnostic mammogram code. Hence, you should report codes 77057 and 77055-GG. “When a diagnostic is performed on the same day as a screening the diagnostic mammogram must be submitted with a GG modifier,” Hembree says.

Note: Your physician may order more films if the screening reveals a potential problem. “According to Medicare, if a patient has an abnormal finding on a screening mammogram, the radiologist who interprets the screening exam may order additional films while the patient is still at the facility,” says Hembree. Thus, Medicare allows radiologists who interpret a screening mammogram to carry on with further investigative steps. Medicare will pay for both the screening and diagnostic exams. 

Check the age of the patient: “Between ages 35-39, Medicare will cover one baseline screening exam. For patients 40 and older, Medicare will cover one screening per year,” Hembree says. Medicare will cover screening mammograms even without a physician order for women who meet age and frequency requirements:

• Under age 35: No payment allowed for screening mammography.
• 35-39: Baseline (pay for only one screening mammography performed on a woman between her 35th and 40th birthday).
• Over age 39: Annual (11 full months have elapsed following the month of last screening).

Tip 4: Watch for Screening in One Breast

Screening mammography codes are ideally intended for mammograms involving both breasts. Medicare covers screening for both breasts. The descriptor of the code 77057 also mentions, ‘bilateral (2-view film study of each breast).’

However, mammography may be done for a woman who had a mastectomy. For a woman with one breast, you’ll probably get into trouble with your insurers if you use a “screening” mammogram and diagnosis codes. In this scenario, you may use 77055 (Mammography; unilateral), which is a diagnostic rather than screening procedure. Also, include an ICD-9-CM code, for example, V10.3 (Personal history of malignant neoplasm of breast). This maps to Z85.3 (Personal history of malignant neoplasm of breast) in ICD-10.

Check with payer preferences: Make sure the ordering doctor’s understanding of screening/diagnostic matches that of your payer’s. If you’re coding for someone under NGS Medicare, New York’s carrier, you may read more on at http://apps.ngsmedicare.com/lcd/LCD_L26890.htm and http://apps.ngsmedicare.com/sia/ARTICLE_A48362.htm.

They show that for NGS Medicare patients, your case could be either a screening or diagnostic mammogram, depending on the ordering physician’s view. Remember, your payer policies can vary, so always check individual policies before you report.

According to the local coverage determination (LCD), a diagnostic mammogram is indicated when: 

• There is short interval follow-up (at six month intervals, for 2 years) necessary for unresolved clinical/ radiographic concerns;
• A personal history of breast malignancy exists. Once clinical and mammographic stability has been established, the routine use of diagnostic mammography over screening mammography is not warranted.

The LCD seems to suggest that even patients with a history of breast cancer can return to “screenings.” 

Some payers may instruct the providers to append modifier 52 (Reduced services) to screening mammogram codes if they need to indicate a unilateral service. “When a unilateral screening is performed, you may report code 77057 or G0202 with a 52 modifier,” Hembree says. 

The NGS article states: “Screening mammography codes 77057 or G0202 and 77052 should be reported whether the mammography is performed unilaterally or bilaterally. The modifier 52 should be appended to the CPT/HCPCS codes when it’s performed unilaterally. When modifier 52 is appended to the screening mammography codes 77057 or G0202 and 77052, it would be assumed that the service rendered was a unilateral mammography. The unilateral mammography would be paid at a reduced rate.”

Tip 5: Highlight the Difference between These Digital Imaging Codes

When your radiologist obtains digital imaging when performing a mammogram, you submit code G0202 (Screening mammography, producing direct digital image, bilateral, all views) for screening mammography and codes G0204 (Diagnostic mammography, producing direct digital image, bilateral, all views) or G0206 (Diagnostic mammography, producing direct digital image, unilateral, all views) for unilateral or bilateral diagnostic mammograms. “Digital mammograms are represented by ‘G’ codes,” Hembree says.

You can also report code +77052 (Computer-aided detection [computer algorithm analysis of digital image data for lesion detection] with further review for interpretation, with or without digitization of film radiographic images; screening mammography [List separately in addition to code for primary procedure]) with 77057 for computer-aided detection applied to a screening mammogram. Similarly, for computer-aided detection with diagnostic mammography, you can report +77051 (Computer-aided detection [computer algorithm analysis of digital image data for lesion detection] with further review for interpretation, with or without digitization of film radiographic images; diagnostic mammography [List separately in addition to code for primary procedure]) with codes 77055 and 77056.

Tip 6: Do Not Forget the Diagnosis Codes

Check the documented findings before you select a diagnosis code. A common finding on a mammogram is a breast mass. In this case, you report ICD-9 code 611.72 (Lump or mass in breast). This corresponds to N63 (Unspecified lump in breast) in ICD-10. Another common instance can be when your radiologist documents that the mammogram is inconclusive and the patient requires additional tests. You should report this with code 793.82 (Inconclusive mammogram). In ICD-10, you may consider R92.2 (Inconclusive mammogram).

For screening procedures, you may choose from the following:

• V76.1x, Screening for malignant neoplasms of the breast
• V76.10, Breast screening unspecified
• V76.11, Screening mammogram for high-risk patient
• V76.12, Other screening mammogram

Buck lists the following conditions as potential for screening mammogram as CMS considers these ‘high risk’ for breast cancer:

• Has a personal history of breast cancer (V10.3)
• Has family history (mother, sister, daughter) of breast cancer (V16.3)
• Had her first baby after age 30 (V15.89)
• Has never had a baby (V15.89)
• A personal history of biopsy-proven benign breast disease (V15.89)

“When the patient has a history of any of the above, assign code V76.11 as primary diagnosis, followed by the code for the designated risk factor as a secondary diagnosis”, says Buck.

Tip 7: Mammography May Be Used As Guidance

Diagnosis and screening are not the only applications for mammograms. Your physician may also use mammography to guide the placement of wires, needles, clips, radioactive seeds, and other devices in the breast. In such situations, you keep a count on how many lesions your physician treated.

For mammographic guidance, you have two new codes effective Jan 1, 2014, i.e. code 19281 (Placement of breast localization device[s] [e.g., clip, metallic pellet, wire/needle, radioactive seeds], percutaneous; first lesion, including mammographic guidance) for the first lesion and code +19282 (Placement of breast localization device[s] [e.g., clip, metallic pellet, wire/needle, radioactive seeds], percutaneous; each additional lesion, including mammographic guidance [List separately in addition to code for primary procedure]) for each additional lesion that your physician treated. 

Tip 8: Learn When You Should Not Report Mammography

You don’t need to report for mammography separately if it is inclusive in the procedure. For example, you may read your physician did a breast biopsy and placed a metallic localization clip using radiologic guidance. He then confirmed the clip placement on a mammogram. 

In this case, depending upon the type of radiological guidance used, you may report code 77021 (Magnetic resonance guidance for needle placement [e.g., for biopsy, needle aspiration, injection, or placement of localization device] radiological supervision and interpretation), 77012 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation). When mammographic guidance is used, you report 19281.These radiologic guidance codes are inclusive of all imaging needed to complete the procedure. You do not separately report the mammogram in this case. Therefore, you will not additionally report any mammography codes like +77051, +77052, 77055, 77056, or 77057.