Radiology Coding Alert

Wait six weeks post-vaccine before scheduling these services.

A routine screening mammogram procedure can help with the early detection of breast cancer, but recently a wrench has been thrown into the diagnostic works, thanks to the addition of the COVID-19 vaccine.

Earlier this year, University of Pennsylvania Medicine radiologists noticed “a rise in axillary lymphadenopathy…on multiple types of breast imaging (mammography, ultrasound and MRI),” (URL: www.pennmedicine.org/updates/blogs/health-and-wellness/2021/march/covid-vaccine-and-mammograms), which was tied to the recent injection of the COVID-19 vaccine. While medical experts will argue it’s crucial for patients to receive the COVID-19 vaccine, radiologists are suggesting that practices wait to schedule annual screening mammograms until six weeks have passed since the patient’s final dose.

How Does the COVID-19 Vaccine Affect the Lymph Nodes?

When a patient is administered the COVID-19 vaccine (91300-91304, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, …), a patient can experience several adverse events (side effects). One such side effect is axillary lymphadenopathy, also known as swollen lymph nodes in the armpits. Swollen lymph nodes are a good thing when it comes to the COVID-19 vaccine, because it means your immune system is responding to the vaccine.

However, while the axillary adenopathy is a normal immunogenic reaction to the COVID-19 vaccine, a radiologist could misinterpret this as an abnormal area on the scan. This finding may require further examination of the area, and if the diagnostic mammogram is performed at a later date, the axillary adenopathy may not be present anymore.

Scenario: A 41-year-old female without personal or family history of breast cancer was referred for a routine screening mammogram and screening breast ultrasound. According to the electronic medical record (EMR), she received the second dose of the Pfizer-BioNTech COVID-19 vaccine in her upper left arm seven days prior.

For this visit, you’ll report 77067 (Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed). Remember, if the radiologist performed a bilateral procedure with two views from different angles, you’ll use 77067.

Now, suppose the screening ultrasound for the left breast indicated an abnormality. The radiologist asked the patient to return for a diagnostic mammography.

For that visit, you’ll report 77065 (Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral) or 77066 (…; bilateral). When looking at the radiologist’s report, pay attention to if the mammogram is performed on one side only or two sides. For instance, if the radiologist performed the mammogram only on the left side, then you will add modifier LT (Left side).

Did the screening mammogram and diagnostic mammogram occur on the same day? If so, you’ll append modifier GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) to the diagnostic mammogram code.

Ask for COVID-19 Vaccination Status Before Scheduling an Exam

Following the administering of the COVID-19 vaccine, a patient’s swollen lymph node may appear on a screening mammogram. While it is important to order a diagnostic mammogram for further examination, if the patient’s medical history indicates they have recently received the coronavirus vaccine, a second screening may need to be performed outside of a six-week window to ensure the lymph nodes have returned to normal.

The Society of Breast Imaging (SBI) released recommendations in recent months regarding screening mammograms for patients with a recent COVID-19 vaccination. The SBI offers the following consideration, “If possible, and when it does not unduly delay care, consider scheduling screening exams prior to the first dose of a COVID-19 vaccination or 4-6 weeks following the second dose of a COVID-19 vaccination” (URL: www.sbi-online.org/Portals/0/Position Statements/2021/SBI-recommendations-for-managing-axillary-adenopathy-post-COVID-vaccination.pdf).

Action step: To avoid patients having to undergo a diagnostic mammogram due to a COVID-19 vaccine adverse reaction, your practice should start asking patients before scheduling breast imaging exams if they have received the COVID-19 vaccine and arrange the visit to take place outside of the recommended six weeks.