Radiology Coding Alert

Should patients referred for mammography with implants always be evaluated with a diagnostic mammo-
gram code (76091, bilateral) as opposed to a screening one (76092)? Coders report conflicting answers from government payers as compared with the current standard developed by the American College of Radiology (ACR).

According to the ACR Standard for the Performance of Diagnostic Mammography (effective 1/1/99), the category of women who have implants is included as one of six indications listed for diagnostic mammograms. The ACR standard goes on to provide this guidance on performance standards: Evaluation of the augmented breast should include standard craniocaudal (CC) and mediolateral oblique (MLO) as well as implant-displacement views, if possible. Evaluation of the augmented breast may require, in some cases, additional tailored or special views for optimal visualization of breast tissues (ACR Standard, Section VI.D).

Some coders argue this standard calls for diagnostic mammograms on all patients with implants. They reason that the standard requires additional views (especially displacement views), which is more difficult for technicians to perform and takes more effort for the radiologists to read. Thus, according to coding experts, compliance with the standard justifies a diagnostic evaluation code whenever an implant is involved.

Medicare carriers and the Health Care Financing Administration (HCFA) Central Office say the answer to the question of whether to always evaluate with diagnostic mammography when implants are involved is no. The question was addressed in most Part B updates.

Stacey Hall, ART, CPC, CCSP, director of corporate coding and documentation for Medical Management Professionals, Inc., a national billing and management firm for hospital-based physician practices, headquartered in Chatanooga, TN, noted this example from Georgias Medicare Bulletin, March 1999: The definition of a diagnostic mammogram is a radiological procedure furnished to a man or woman with signs or symptoms of breast disease, or a personal history of biopsy-proven benign breast disease. This definition does not allow for coverage of the breast implant unless the patient meets the specific terms of the diagnostic mammogram description. Also, a screening mammogram service must be, at a minimum, a two-view exposure (that is craniocaudal and a mediolateral oblique view) of each breast. The regulation recognizes that certain screening mammograms (e.g., in the case of a patient with an implant) may require more than a two-view exposure of each breast.

In other words, the presence of an implant alone does not meet the definition of a diagnostic mammogram. And since the definition of screening mammography allows for additional views, if there are no other appropriate signs, symptoms, conditions, or history, a patient with implants would be evaluated with screening mammography ( 76092 ) even if additional views are necessary for proper imaging.

Asymptomatic Post-Mastectomy Mammograms

This is another special mammography situation that has raised coding issues. After a patient has had one breast removed by mastectomy, should subsequent mammography on the remaining breast be a unilateral diagnostic mammogram (76090) or considered a screening? If the post-mastectomy patient is now free of symptoms, the mammogram should be a screening evaluation subject to local payer guidance. Hall also observes that if the patient meets the payer criteria for high-risk screening mammography, then use the ICD-9 code V76.11 (screening mammogram for high-risk patient). For example, Hall cites these criteria from the Tennessee Medicare Bulletin, December 1997, which states the high-risk category includes:

a personal history of breast cancer;

a mother, sister, or daughter who has breast cancer;

not given birth prior to age 30; and

a personal history of biopsy-proven benign breast
disease.

In addition, check to see if your local carrier instructs coders to use a -52 modifier (reduced services) with the screening mammogram code for asymptomatic post-mastectomy patients who are having the one remaining breast evaluated (screening is assumed to be bilateral, so since there is only one breast the services required are reduced). Advice to use this modifier has been reported, for example, in Minnesota and Louisiana. Thus, if the patient is determined to be asymptomatic yet high-risk, you should code for a screening mammogram (76092, possibly with a
-52 modifier, depending on your local carrier) and use a V76.11 diagnosis code.