Radiology Coding Alert

Even though it is a common imaging procedure, mammography offers no shortage of bewildering questions for radiology coders. At the heart of the confusion are issues that cloud the distinctions between screening and diagnostic mammogramsdistinctions that make coding for patients who have been treated for breast cancer especially challenging.

Professional coders across the country report wildly different local Medicare policies regulating mammograms for former breast cancer patients, and stress the need for imaging centers to keep current of local requirements that affect reimbursement levels.

Is History of Breast Cancer Justification?

Many local policies follow the lead of the Health Care Financing Administration (HCFA) and allow radiologists to assign diagnostic mammography codes (76090, mammography; unilateral; or 76091, bilateral) to patients who have had a personal history of breast cancer.

For example, the local Medicare policy in Pennsylvania allows reimbursement for diagnostic mammograms for men or women who have a personal history of breast cancer (V10.3), along with those who exhibit signs and symptoms of breast disease (i.e., lump or mass in the breast611.72) or have a personal history of biopsy-proven benign breast disease (i.e., solitary cyst of breast610.0).

Similar coding requirements can be found in
Connecticut. According to Darlene Zase, BS, CMPE, administrative director for Bridgeport Radiology Association in Fairfield, Conn., radiologists there are allowed to bill mammography as diagnostic for at least five years after patients have been treated for cancer. (Five years post-therapy is often accepted by medial professionals as the point when cancer treatment can be considered successful.)

When Diagnostic Mammograms Are Allowed

Other payers, however, have implemented restrictions on diagnostic mammograms for post-treatment breast cancer patients.

One Radiology Coder in Washington state, for instance, has observed a recent policy change that restricts radiologists ability to assign the diagnostic mammography code. I had always assumed there was a national policy on this, she says. But we have begun seeing rejections from Medicare for diagnostic mammograms on patients who are three or more years post-treatment and are asymptomatic. This seems like a very arbitrary time frame to definitively state that mammograms that had been diagnostic now suddenly become screening (76092, screening mammography, bilateral [two view film study of each breast]).

According to April Brazinsky, CCS, coding specialist for the Community Hospital of the Monterey Peninsula in California, colleagues throughout the country share this coders frustration. We are seeing time frames like this established by local carriers or fiscal intermediaries everywhereand there are great differences from region to region.

Brazinsky notes that, in her area, the regulations are far more conservative than three years. Here in northern California, our regulations state that a screening mammogram must be ordered unless the patient has current cancer symptoms. Once the cancer is treated, we are required to code all mammograms as screening again, no matter how recent the illness.

She notes that if a patient is due for her annual mammogram while being treated for cancer, the payer accepts the diagnostic CPT code 76091. Perhaps she is in the middle of a chemotherapy cycle or taking Tamoxifen when she comes in, Brazinsky says. If she is under cancer treatment, our carrier considers that the patient has current symptoms and the mammogram is diagnostic.

Once the treatment has ended, however, 76092 again must be assigned.

Likewise in New York, the local Medicare payer notes that while diagnostic breast evaluation may be indicated in cases of personal history of malignancy, the routine use of diagnostic mammography instead of screening mammography is not warranted once clinical stability has been established.

Diagnosis Must Support Screening Mammography

When a local carrier determines that a breast cancer patients mammogram once again must be considered a screening evaluation, coders must follow specific diagnostic coding requirements.

In many instances, a patient who has had breast cancer meets carrier criteria for high-risk screening mammography, and coders should assign V76.11 (screening mammogram for high-risk patient). The local carrier in Tennessee, for example, lists personal history of breast cancer as justification for a V76.11 diagnosis code, along with several other personal or familial medical characteristics.

Elsewhere, however, this is not the case. Brazinsky notes that the local Medicare payer in northern California disallows V76.11and instead requires that V76.12 (other screening mammogram) be stated as the primary diagnosis code for patients. Clinically speaking, V76.11 most closely describes a breast cancer patients medical status. However, you must conform to your carriers demands. As a matter of fact, the software that this payer uses wont even accept the combination of a V76.11 diagnosis code with CPT code 76092. It simply kicks the claim out of the system.

Coding for Post-mastectomy Patients

Many coders wonder how to code subsequent mammography on the remaining breast of a breast cancer patient who has had a mastectomy.

Generally speaking, if the post-mastectomy patient is free from symptoms, the mammogram should be coded as a screening evaluation, subject to local payer guidelines. Few carriers allow diagnostic mammograms in these situations. In most instances, diagnosis code V76.11 is assigned because it indicates that the patient is high-risk. In her region, Brazinsky notes, the carrier also requires that coders report V10.3 (personal history of breast cancer) and V45.71 (acquired absence of breast) for post-mastectomy mammograms.

In addition, some carriers will require that coders assign a -52 modifier (reduced services) with the screening mammography code for asymptomatic patients who are having the one remaining breast evaluated. Typically, a screening mammogram is defined as bilateral. Therefore, when only one breast is being evaluated, payers expect the lower level of service to be reported.

Breast Reconstruction with Implants

In addition, some women elect to have their breast reconstructed with implants, which raises further coding questions. According to Cindy McMahan, CPC, an independent coding consultant based in Albany, Wis., most local Medicare policies applying to post-mastectomy patients with implants mirror those for patients treated for breast cancer, but who did not undergo a mastectomy. In other words, if the carrier accepts a personal history of breast cancer as a reason for a diagnostic mammogram in cancer patients who did not undergo a mastectomy, it is likely that the carrier also will allow a diagnostic evaluation on a breast reconstruction with implants.

Coders should recognize that, in order to bill for mammograms performed on patients with implants, it is necessary to have a complete medical history and a thorough understanding of your carriers policies, notes McMahan. The simple presence of an implant is not the determining factor of a diagnostic mammogram.

Some coders argue that mammograms on patients with implants should always be assigned a diagnostic code because implants often require additional views beyond the two (craniocaudal and mediolateral oblique) that are typically included in a screening evaluation. These extra viewsparticularly displacement viewsare more difficult for the technologist to obtain, and require more effort for the radiologist to read. In fact, the American College of Radiology (ACR) Standard for the Performance of Diagnostic Mammography includes implants as one of six indications for diagnostic mammography.

Nonetheless, most carriers do not agree with this reasoning. One of the reasons payers dont accept this approach is that screening mammography services are defined as a minimum of two views, according to the Code of Federal Regulations, Brazinksy says. So, from their perspective, displacement views clearly fit into the definition of screening mammography if there are no other breast symptoms.

Coding tip: Radiology coders should remember that HCFA states that both screening and diagnostic mammograms are effective tools in detecting cancer, and that mammography must be performed as ordered by the attending physician. However, if radiologists observe abnormalities as they view screening films, they may order additional views without an order from the referring physician. If the additional views are taken on the same day, the screening mammogram becomes a diagnostic study and should be assigned code 76091 (do not also report the screening study). If the patient has left the imaging center and returns another day for the additional views, the original mammogram may be coded as a screening service (70692), and the follow-up session as diagnostic (76091).