Radiology Coding Alert

Confusion over the guidelines for coding mammograms following breast biopsies creates enough of a ruckus to make you think New Year's bells are still clanging in your ears.

If a breast biopsy was performed with US guidance, many people are unsure whether you will be allowed to code and bill a separate diagnostic mammogram (76090, Mammography; unilateral) with clip placement confirmation (+19295, Image guided placement, metallic localization clip, percutaneous, during breast biopsy). The good news is that there is support for this code combination so if you're careful and provide solid documentation, you may get paid.

However, if a radiologist performs a breast biopsy using stereotactic or mammographic guidance, then the follow-up mammogram is bundled into that procedure. Most coders understand that in this case, you can't code or charge for a diagnostic mammogram. The follow-up mammogram is always bundled into 76095 (Stereotactic localization guidance for breast biopsy or needle placement [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation) and 76096 (Mammographic guidance for needle placement, breast [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation).

We had to do a lot of research before we got the answer" " says Diane Huston CPC RCC a quality-assurance auditor with Lexon Medical Las Vegas a billing service with offices located nationally and in Nevada.

Like many other carriers Upstate Medicare Division (UMD) the Medicare carrier in upstate New York does not have specific edits against billing clip placement with a stereotactic biopsy. However it still maintains that if the protocol for the stereotactic biopsy with a clip calls for a postoperative mammography to check placement then you shouldn't bill for the follow-up mammography.

Such a practice would likely fail in a postpayment audit on the grounds of lack of medical necessity. This postprocedure mammogram may be considered a quality-assurance function by this payer.

The reason UMD has not put an edit in place is that it would eliminate legitimate preoperative diagnostic mammograms Huston says.

The American College of Radiology's (ACR) Committee on Coding & Nomenclature has issued an opinion stating "that it is not appropriate to code for a unilateral diagnostic mammogram for verification of clip placement post-stereotactic breast biopsy since these images are included in the placement of the clip localization CPT 19295 (provided that the guidance and exam was done by the radiologist)."

The committee goes on to say that "if a stereotactic biopsy with clip placement is done by a surgeon who then requests a radiologist to interpret a two-view mammogram to confirm clip localization it would be appropriate for the radiologist to code a unilateral diagnostic mammogram (76090)."

If this sounds a little confusing to you you're not alone. Huston found that her doctors were not satisfied with the information from ACR. She submitted another question to ACR asking whether mammograms were billable if another doctor was the one actually performing the biopsy.

In a letter dated Nov. 15 2002 ACR responded: "It must be remembered that the scout views of any subsequent needle localization procedure will suffice (when compared with the prebiopsy mammograms) to determine if in fact the clip is at the location of the prior lesion and also would not be coded separately."

In other words "regardless of whether a surgeon or radiologist performs the breast biopsy the mammogram is not separately reportable " Huston had to tell her physicians.

The news isn't all as bleak as a January night. ACR's opinion paper states that "It is appropriate to bill for a verification mammogram if the biopsy is done under ultrasound guidance." Their rationale for allowing ultrasound guidance is that it is a separate procedure using a different imaging modality. ACR also contends that the clip placement is not essential to the successful completion of the ultrasound guidance procedure.

"ACR's position makes a lot of sense especially if you don't have a baseline mammogram done that same day " says Herb Bruss RT(R) MA RCC a consultant with The Rybar Group in St. Joseph Miss.

Huston and other coders have taken refuge in an informal opinion written by a Radiology Business Managers Association member: "If ultrasound guidance is used and mammography is done to verify position of either a localization needle/wire or metallic clips then it is appropriate to code for a unilateral diagnostic mammogram."

Remember that there is a "big difference" between "authoritative coding guidance" and "opinion " says Cindy Parman CPC CPC-H RCC co-owner of Coding Strategies Inc. an Atlanta-based firm. Authoritative guidance comes from the AMA (because they own the codes) and the insurers (because they pay for the services). "Everyone else including ACR and RBMA has opinions that will not carry weight as coding guidance " Parman says. However she says "ACR opinion may be considered a 'standard of practice ' which is great to use when discussing changes to policy with insurance payers."

On the other hand Florida Medicare interpreting CMS guidelines strictly contends that needle placement or tissue marker (whether ultrasound- or mammography-guided) is bundled in the localization. Just as you wouldn't expect the contractor to charge you extra for using a level to check his work on your house Florida sees clip placement as an essential quality check to the procedure.

Other carriers may have different policies so this is one of those questions that each practice needs to work out on an individual basis.

Jeff Fulkerson BA CPC coding specialist at the Emory Clinic in Atlanta agrees with this interpretation and adds that any filming done as part of the procedure should be included in the procedure itself.

"The only exception to this rule would be if a clinic does an ultrasound-guided biopsy and clip placement and on the same day also has to do a unilateral diagnostic mammogram on the same breast perhaps because the patient is having postoperative pain or develops a hematoma " Fulkerson remarks. "Then I could see billing it."

Bruss agrees: Every so often it is appropriate to bill that follow-up ultrasound-guided mammogram but you want to be really careful and have loads of documentation. "And of course " he says "medical necessity is key in everything."