Radiology Coding Alert

Incorporate payer-specific submission rules into your practice guidelines.

Reports of various practices receiving denials for same-day screening and diagnostic mammograms have been swirling in recent months. While the denials are exclusively from commercial payers, it’s important that practices are able to determine whether or not the fault lies with the payer alone or the practice.

Recap these strict guidelines for submission of same-day screening and diagnostic mammograms to make sure you and your practice are doing everything in your power to avoid these frustrating denials.

Refer to CMS Guidelines for Modifiers GG, 59

“The Centers for Medicare and Medicaid Services [CMS] have very specific rules on how coders should report diagnostic and screening mammographic services performed on the same day,” says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. Medicare explains when and how to append modifier GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) in CMS Transmittal 3844, Section 20.6:

• “For A/B MACs (B) claims, providers submitting a claim for a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier ‘GG’ to the diagnostic mammography. A modifier ‘GG’ is appended to the claim for the diagnostic mammogram for tracking and data collection purposes. Medicare will reimburse both the screening mammography and the diagnostic mammography.”

However, Medicare only offers part of the equation in the transmittal. Chapter 9 of the National Correct Coding Initiative (NCCI) Policy Manual further elaborates:

• “Screening and diagnostic mammography are normally not performed on the same date of service. However, when the two procedures are performed on the same date of service, Medicare requires that the diagnostic mammography HCPCS/ CPT^® code be reported with modifier GG and the screening mammography HCPCS/ CPT^® code be reported with modifier 59 (Distinct procedural service).”

For example, if a patient receives a bilateral screening mammogram followed by a bilateral diagnostic mammogram on the same day, the coding would be as follows:

• 77067-59, (Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed))
• 77066-GG, (Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral).

Avoid Common Submission Mistakes

While Medicare’s guidelines on the submission of these claims are crystal clear, other payers do not necessarily have to follow by the same rules. Therefore, receiving a denial from a commercial payer isn’t necessarily out of the question. However, before assuming that the payer erroneously denied the claim, you will want to take a few steps to make sure the denial is not the result of a coding or submission mistake.

The most common mistake coders make involving the submission of same-day screening and diagnostic mammographic services is submitting each service on separate claims. Some Medicare Administrative Contractors (MACs), such as NGSMedicare, specifically state that coders should “bill both screening and diagnostic codes on same claim.”

Depending on the payer, a separate claim submission may trigger a red flag in its claims processing system. The most common denial code with these submissions is CO 4 (The procedure code is inconsistent with the modifier used, or a required modifier is missing), which means that the payer very well may be processing the diagnostic and screening services separately. This can often be tricky for coders due to the fact that they may code each claim at separate instances. Assuming the services are performed hours apart, it’s up to the coder to confirm that no other services have been performed on the same day. This means that for all diagnostic mammogram services, coders should make sure to check the patient’s chart for any additional services before submitting the claim.

Rule: This advice is an important rule for all services, not just screening and diagnostic mammograms. Many practices could prevent numerous annual denials if they had a system in place to flag for additional services performed on the same day. Some electronic health records EHR “all in one” coding software programs are able to flag for separate, same day procedures, but others are not.

Use Payers to Establish Practice Guidelines

If you still receive a denial despite abiding by Medicare’s submission guidelines, then your next step in the process is to contact the payer. In fact, there are certain payers who may or may not require the use of modifiers GG and 59 on the claims in order to be paid.

“The truth is, not all payers follow Medicare rules, guidelines, and fee schedules,” says Leslie Johnson, CPC, coding and auditing consultant at Oasis Medical and Surgical Wellness Group, LLC, in Glen Rock, New Jersey.

“A company who instructs their coders to follow only CPT^® or only Medicare rules is likely experiencing a slow leak in overall revenue from additional hands touching the same claim multiple times. They can measure a coder’s productivity by how many charges they code; they can measure a collector’s productivity by how many charges they collect on. However, they can’t measure the total time spent on any single claim coding, posting, researching and correcting, resubmitting a claim once, maybe even twice or more,” Johnson explains.

That’s why contacting each payer to determine its stance on these claims will go a long way in terms of establishing future practice guidelines. Having each coder working in a practice following the same payer-specific instructions is important in terms of preventing denials and creating a cohesive, efficient work environment.