Radiology Coding Alert

Hint: 77067 is the only screening mammography code.

Coding mammography exams may be fairly routine, but several factors can trip up even the most experienced radiology coders. Factors that affect your code selection include laterality, if the patient is presenting signs or symptoms, and what to do if a procedure doesn’t fully line up with the code descriptor.

Radiology Coding Alert is here to separate the news from the nonsense with three mystifying mammography myths.

Myth 1: Screening Mammography Exams Require Signs or Symptoms of Breast Disease

The term “signs or symptoms of breast disease” is one of the differentiating factors between screening and diagnostic mammography exams. However, there is a word that precedes “signs or symptoms of breast disease” that indicates whether you’ll assign a screening or diagnostic CPT^® code.

If the patient’s provider orders an exam when the patient presents to their initial examination with signs or symptoms of breast disease, then you’ll assign one of the following diagnostic mammography codes:

• 77065 (Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral)
• 77066 (… bilateral)

On the other hand, if the patient presents to their initial examination without signs or symptoms of breast disease, then you’ll assign the following screening mammography code:

• 77067 (Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed)

In addition to the patient presenting signs and symptoms, Medicare indicates a diagnostic mammography is furnished to a patient with a personal history of breast cancer or a personal history of biopsy-proven benign breast disease.

Fast fact: While diagnostic mammography is offered for male and female patients with signs or symptoms of breast disease, Medicare screening mammography is designated only for women.

Several factors play into why a physician orders a diagnostic mammography over a screening exam. “If the patient presents with symptoms, if the exam is a follow-up to a screening with findings, or if the exam is a follow-up to a previous study that had findings that weren’t clearly defined,” says Ruby O’Brochta-Woodward, BSN, CPC, CDEO, CPMA, CPB, CPC-I, CPCO, COSC, CSFAC, RCC, coding supervisor of Consulting Radiologists Ltd. in Eden Prairie, Minnesota.

O’Brochta-Woodward also presented other scenarios that would warrant a diagnostic mammography exam:

• Patients currently diagnosed with breast cancer
• Patients with a metastatic disease where the breast is the suspected source of the disease
• Patients with axillary lymphadenopathy (swelling of the armpit lymph nodes) of undetermined cause
• Patients with biopsy-proven breast disease

Myth 2: You Should Assign 77065 for Unilateral Screening Mammography Exams

By reviewing the truth to the first myth, you can easily dispel this myth. If you have a report where the radiologist performed a unilateral screening mammography exam, you can only assign 77067. While 77065’s descriptor includes the term “unilateral,” the code is inherently a diagnostic exam. Code 77067 is designated for screening mammography exams, whereas 77065 is assigned for a unilateral diagnostic mammography.

The descriptors for 77065-77067 also include the words, “unilateral” and “bilateral,” which represent procedures performed on one or both sides of the body, respectively. This means if the provider performs a diagnostic mammography on either the patient’s left or right breast, but not both, you’ll assign 77065 for a unilateral diagnostic mammography.

You should note that since 77067’s descriptor includes “bilateral,” you’ll want to append a modifier to indicate that the entire procedure wasn’t performed. “You’ll use 77067 as that is currently the only screening code available, but you then append modifier 52 [Reduced services] to indicate that it is a unilateral study only,” O’Brochta-Woodward says. Reporting 77067-52 shows the payer that a screening mammography was performed on one breast.

Smart move: “It is important to check with the insurance carrier as they may have different guidelines” for coding unilateral screening mammograms, adds Kristen Bensel, CPC, CPMA, CDEO, medical coder of Yellowhawk Tribal Health Center in Pendleton, Oregon.

Myth 3: You May Code Screening on 1 Side and Diagnostic Mammography on the Other Side on the Same Day

This is tricky myth to decipher, but take a look at a hypothetical situation to explore why the myth is false.

Scenario: A patient presented to her primary care physician (PCP) for a routine physical. During the evaluation and management (E/M) visit, the patient mentioned she felt a lump in her left breast a few days ago. The PCP informed the patient that she was due for her annual screening mammogram. The PCP ordered a unilateral screening mammogram of the right breast and a diagnostic mammogram of the left breast.

Is it possible to report 77067-52-RT and 77065-LT together? No, you cannot report a unilateral screening mammogram on one breast and a unilateral diagnostic mammogram on the other breast during the same encounter. “This will be billed as a diagnostic exam,” O’Brochta-Woodward says.

“If two separate types are done during one visit, this would not be possible,” Bensel says. For the scenario posed above, “it would be most appropriate to do bilateral diagnostic mammography,” Bensel adds.

A provider may only perform a screening mammography on an asymptomatic patient with the purpose of early detection of breast cancer. If the patient is exhibiting any signs or symptoms of breast disease, such as a lump in the left breast, then the provider can only order or perform a diagnostic mammography regardless of whether the symptom is in one breast or both.