Radiology Coding Alert

Do you need to report CAD separately? Find out.

Radiologists may use computer-aided detection (CAD) with screening and diagnostic mammography to interpret the mammogram with greater accuracy. The software examines certain areas of the mammogram to identify potential problems.

Know how to report screening and diagnostic mammography exams with CAD that occur during the same encounter.

Separate Screening From Diagnostic Mammography

Screening: Providers routinely perform screening mammography to detect breast cancer when the patient doesn't exhibit any symptoms of breast disease. According to the Medicare National Coverage Determinations [NCD] Manual, Section 220.4, a screening mammography must be "at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast" (www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/ncd103c1_Part4.pdf). The NCD indicates diagnostic mammography requires an order for Medicare to cover it, but the NCD does not list the same requirement for screenings.

Screening to diagnostic: If an abnormality is detected during a screening mammography, the provider may order a diagnostic mammography. The radiologist performs this procedure to further evaluate the abnormality.

Diagnostic: A treating provider may order a diagnostic mammography if the patient has signs or symptoms of breast disease, a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease.

Upgrade Your Coding With This Breakdown of CAD

The CAD software features computer algorithm analysis based on thousands of breast cancer cases to pinpoint certain areas on a mammogram that may be suspicious and deserve a closer examination. The software is designed to help radiologists find small breast cancers in early stages.

When the CAD software analyzes the mammography images, the software identifies false findings, distinguishes minute details in the images, and marks any abnormalities for further evaluation by the provider.

Given the efficiency of the software and assistance provided when interpreting the mammography results, are there patients for which using CAD is worth the extra step? "A physician may order a mammogram with CAD if the patient has dense breast tissue," says Taylor Berrena, COC, CPC, CEMC, CFPC, coder II at MD Anderson Cancer Center at Cooper in Yorktown, Virginia.

The AMA CPT^® code set features three mammography codes that include CAD:

• 77065 (Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral)
• 77066 (… bilateral)
• 77067 (Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed)

You'll notice the CPT^® descriptors of 77065-77067 list "CAD when performed." This means you may report a code from 77065-77067 regardless of whether CAD is used during the procedure. CAD is included in, but not required for, these screening and diagnostic mammography codes, and the software use doesn't need to be reported separately. At the same time, the ordering physician doesn't have to specify the use of CAD when an order is issued for screening or diagnostic mammography.

Additionally, if the provider performs screening or diagnostic mammography without CAD, you'll choose from the same codes.

Code This Mammography Encounter

Scenario: A patient with no prior personal history of breast cancer visits a radiology practice for her annual screening mammography. Due to the patient's dense breast tissue, the patient's general practitioner (GP) ordered a bilateral screening mammography with CAD. The software detects and the radiologist confirms a suspicious area in the upper outer quadrant of the patient's left breast during the procedure. Consequently, the radiologist performs a diagnostic mammography with CAD of the left breast during the same encounter, interprets the results, and issues a diagnosis of an unspecified lump in the upper outer quadrant of the left breast.

In this scenario, the radiologist received an order to perform a screening mammogram with CAD, but after interpreting the results and finding an abnormality, the radiologist decided to perform a diagnostic mammogram with CAD. To code this encounter, you'll start by assigning 77067 to report the bilateral screening mammography with CAD. Next, you'll need to code unilateral diagnostic mammography with CAD.

"If a patient received a screening mammogram with CAD on one encounter, and the results warranted a unilateral diagnostic mammogram with CAD at the same encounter, you can report the two services on the same date of service as long as modifier GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) is appended," Berrena says.

In the scenario above, the results showed a suspicious area, which demonstrates the medical necessity for a diagnostic mammography on the same day. For this scenario, you'll append modifier GG to diagnostic mammography code 77065 on the next claim line under 77067.

The documentation needs to also show the suspicious area that allows for the additional procedure. For instance, Medicare Administrative Contractor (MAC) CGS Administrators local coverage article A56448 states, "If the examination began as a screening mammogram and additional films were ordered based on abnormal results, the specific abnormality must be documented in the record" (>www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56448&ver=15&=).

Next, you'll need to identify any diagnosis codes for the results. The radiologist documented their findings as an unspecified lump in the upper outer quadrant of the left breast. Codes in the N63.- (Unspecified lump in breast) ICD-10-CM category can be expanded to specify laterality and the affected quadrant. You'll assign N63.21 (Unspecified lump in the left breast, upper outer quadrant) to report the radiologist's findings.

In summary, you'll assign the following codes:

• CPT^®: 77067
• CPT^®: 77065-GG
• ICD-10-CM: N63.21