Radiology Coding Alert

Hint: Asymptomatic patients' mammograms are usually 'screening'

Think your mammogram coding skills are top-notch? Test your ability to determine whether you would report a screening or diagnostic mammogram in these clinical scenarios, and then read the answers to rate yourself.
 
Questions:

Scenario 1: A 40-year-old woman notices a lump in her breast six months after her last screening. The radiologist assigns diagnosis code 611.72 (Signs and symptoms in breast; lump or mass in breast).

Scenario 2: A 52-year-old woman presents for a routine screening that reveals a mass. The physician orders a unilateral diagnostic procedure for later that day.

Scenario 3: A patient with cancer in remission presents for a diagnostic mammogram.

Answers:

Answer 1: Diagnostic. Other than cancer symptoms, CMS offers no diagnosis code to substantiate medical necessity for a diagnostic mammogram. But Medicare and other payers will reimburse for diagnostic mammograms based on specific symptoms that indicate the potential for breast cancer, including ICD-9 611.72 .

Because the patient presented with one mass limited to one breast and the physician ordered a unilateral diagnostic mammogram, you should report 76090 (Mammography; unilateral).

Answer 2: Screening and diagnostic. When a routine screening shows an abnormality and requires a diagnostic mammogram on the same day, you should report both the code for the screening mammogram (76092, Screening mammography, bilateral [two view film study of each breast]) and the code for the diagnostic mammogram (76090) as well.

Most Medicare carriers advise coders to sequence the screening code, 76092, as the primary procedure performed and link it to the appropriate V code, most likely V76.12 (Special screening for malignant neoplasms; breast; other screening mammogram).

List the diagnostic mammogram, 76090 (or 76091 if your physician orders a bilateral study), second and link it to either the diagnosis code 611.72 or a more specific exam finding. You should report the unilateral diagnostic mammogram code because tests found no bilateral masses and the unilateral service was medically indicated.

If you perform this procedure on a Medicare patient, append modifier -GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) to the diagnostic mammo-gram code.

Answer 3: Diagnostic. When a patient with cancer in remission presents for a follow-up diagnostic mammogram, use V10.3 (Personal history of breast cancer). Medicare considers either screening or diagnostic mammograms (determined by the attending physician's  order) as an integral component of managing aftercare for patients in remission.

Note: Advice for the Coding Quiz answers was provided by Heather Corcoran, coding manager at CGH Billing Services, a medical billing firm in Louisville, Ky.