Code Abnormal Findings on Radiology Screening Exams With This Guide
Find out which diagnosis codes to report. The Centers for Medicare & Medicaid Services (CMS) cover several screening imaging services for beneficiaries when the patients are eligible. For providers, understanding Medicare coverage rules for screening imaging exams can prevent surprise denials and help ensure your radiology practice receives proper reimbursement for the services rendered. Healthcare providers bill radiology and other diagnostic services under Medicare Part B to Medicare carriers and A/B Medicare Administrative Contractors (A/B MAC) using acceptable HCPCS Level II codes for radiology and other diagnostic services taken primarily from the CPT® code set. Continue reading to learn how you should code radiology screening exams with abnormal or unusual findings. Know When Physicians Order Radiology Screening Exams Certain radiology screening services provided under Medicare are part of the broader category of nonlaboratory imaging tests that help doctors detect, diagnose, or monitor illnesses or conditions. Radiology screenings, such as X-rays, CT scans, magnetic resonance imaging (MRI), ultrasounds, nuclear medicine, and positron emission tomography (PET) scans, help physicians identify or rule out medical conditions, injuries, or abnormalities, and certain tests are covered for preventive purposes to assist providers in early detection of possible issues. When physicians order screenings for a Medicare beneficiary it is important to check the national coverage determinations (NCDs) and local coverage determinations (LCDs) for covered screenings. NCDs and LCDs specify whether a given screening is covered, covered with limitations, or excluded entirely. In short, Medicare considers radiology screening coverage to ensure patients receive necessary, medically appropriate imaging that supports diagnosis, treatment, or prevention, while maintaining compliance with federal coverage rules. Identify the Different Medicare Screening Services Medicare-covered screening services are based on U.S. Preventive Services Task Force (USPSTF) recommendations, which Medicare develops into the NCD and LCD policies for screening coverage under Part B. Generally, those enrolled in Medicare Part B are eligible, and some tests are allowed annually (for example, screening mammogram), while others are once in a lifetime (for example, abdominal aortic aneurysm screening for high-risk men). It is important to note that most screening services do not have patient cost-sharing. As with all Medicare services, they must be reasonable and necessary, and submitted with the correct CPT® and diagnosis codes in accordance with Medicare policy for the service performed. Medicare covers a wide range of screening and preventive services when ordered by a treating provider for medically necessary purposes, including but not limited to: The list of Medicare preventive screenings is not fixed. Medicare regularly evaluates the clinical value of new services, informed by the USPSTF and other bodies to update covered screenings. CMS bases its updates on regulatory changes, which are made through formal rulemaking processes and published in the Federal Register. CMS then updates the Medicare Benefit Policy Manual to reflect changes for the new services. Choose Diagnosis Codes for Screening Exams According to ICD-10-CM Official Guidelines, Section I.C.21.c.5, screening is defined as testing asymptomatic individuals to detect “disease or disease precursors” early, so that “early detection and treatment can be provided.” If a confirmed finding is discovered during a screening, you can assign the condition code as an additional diagnosis alongside the Z code for the screening encounter. Usually, when a patient presents for a screening exam without a confirmed diagnosis or complaint, the NCD or LCD policy will determine the diagnosis code assigned to support the service. Typically, the primary diagnosis code is a Z code, which includes “Persons encountering health services for examinations.” Following the appropriate policy guidance will greatly influence successful diagnosis code assignment to support the screening exam and reimbursement. For example, a screening mammography is covered for women ages 40 and older, with copayments and deductibles waived for preventive services. You’ll assign ICD-10-CM code Z12.31 (Encounter for screening mammogram for malignant neoplasm of breast) to report a screening mammogram. Additionally, CMS guidelines specify intervals for routine screening, typically annually for women 40 and older, though individual risk factors may influence timing. If frequency guidelines are not followed it may lead to a frequency denial, despite the service being covered as a screening. Learn How to Report Unusual Findings You’ll assign diagnosis codes for unusual or abnormal findings from a screening in accordance with ICD-10-CM Official Coding Guidelines. Examples of unusual or abnormal findings diagnosis codes include: Appropriate diagnosis should be assigned with the screening condition, followed by any finding supported by the radiology report. You should always check the Alphabetic Index in the ICD-10-CM code set to confirm whether a symptom/sign/abnormality belongs in Chapter 18 or another chapter, and follow sequencing rules to avoid double coding. Test Your Knowledge With Real-World Scenarios Scenario 1: A provider orders a bilateral screening mammogram for a Medicare patient without any signs or symptoms. The radiology report indicates no abnormal findings. Assign CPT® code 77067 (Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed). You’ll then use Z12.31 to report the reason for the imaging procedure. Scenario 2: A physician orders a bilateral screening mammogram for a Medicare patient without any signs or symptoms. However, the radiology report indicates an abnormal finding without a definitive diagnosis and recommends an ultrasound. In this scenario, you’ll use 77067 to report the screening. Use R92.8 as the secondary diagnosis code to show that the provider discovered an abnormal finding when reviewing the images. David Shaw, BS, CPC, Senior Consultant, Pinnacle Enterprise Risk Consulting Services
