Radiology Coding Alert

A 40-year-old female is referred by her primary physician to radiology for a screening mammogram. She has no initial signs or symptoms. On the same day as the screening (perhaps even within an hour), the radiologist interprets the screening results as abnormal and orders additional breast imaging right away.

When a screening mammogram (76092) becomes a diagnostic mammogram (76090, unilateral or 76091, bilateral) on the same day of service, the coder faces a number of challenging questions that must be answered in order to get accurately paid.

1. Is it correct to code the diagnostic mammogram and not the screening? Once the radiologist orders additional films after finding an abnormality as a result of screening, all on the same day of service, the mammography has become a diagnostic procedure, says Stacey Hall, ART, CPC, CCSP, director of corporate coding and documentation for Medical Management Professionals, Inc., in Knoxville, TN (a billing and practice management services firm). So, in this instance, the coder should not code for a screening mammogram. Instead, he or she should use the appropriate diagnostic code (76090, unilateral, left or right breast, or 76091, bilateral mammogram).

2. Is the GH modifier required for payment? Payment for a properly coded diagnostic mammogram should not be a problem with or without the modifier. However, the consensus among experienced coders is to use the GH modifier as a reporting mechanism to indicate that the diagnostic mammogram was converted from a screening on the same day of service. Hall adds that, the GH modifier was established by HCFA mainly for the purpose of collecting data on the number of diagnostic mammograms performed on Medicare patients as a result of screenings on the same day. The reason to use this modifier is to follow Medicare reporting procedures, but you wont find this modifier in AMAs CPT manual.

This actually means coders have a choice. If your policy is to limit the use of special modifiers whenever possible, the coder may want to use the GH where applicable for Medicare patients only. On the other hand, if this is another instance of Medicare leads, other payers follow and you wish to use this modifier consistently, the coder may want to use the modifier for all payers, relates Hall.

3. Is the choice of ICD-9-CM codes restricted in any way? While screening mammograms use the ICD-9-CM code V76.12 (special screening examination for malignant neoplasms, breast, unspecified), once the mammogram becomes diagnostic, the claim is subject to Medicare and other payer requirements for appropriate (payable) diagnoses to support medical necessity. For the administrative record, this does not call for [...]