Radiology Coding Alert

October is Breast Cancer Awareness Month, and women who have postponed routine screenings and exams should be urged to make appointments promptly for these services. The publicity likely will result in more appointments for mammograms, more advanced diagnostic studies on patients with uncertain findings, and more charges that must be coded correctly to optimize reimbursement.

Among the breast health services that are likely to see an increase during October are mammography, breast ultrasound, stereotactic breast biopsies, needle core biopsies and localization wire placement. Each radiologic procedure offers a wide range of coding challenges, which coders must understand to ensure their practices receive prompt and appropriate payment.

Routine Screening and Diagnostic Mammography

Women 40 years and older routinely are referred to a radiologist or imaging center annually for a screening mammogram. In most cases, these women are asymptomatic, and the study is conducted to make sure there is no underlying indication of cancer. According to Stacey Hall, RHIT, CPC, CCS-P, director of corporate coding for Medical Management Professionals Inc., a national billing and management firm for hospital-based practices in Chattanooga, Tenn., screening mammograms are reported with code 76092 (screening mammography, bilateral, [two-view film study of each breast]). The diagnosis code for screening mammography is ICD-9 V76.12 (other screening mammogram).

Although the procedure code specifies a two-view study of each breast, she notes coders must be aware that there are times when additional views may be taken. These most often occur with women who are large-breasted or who have implants. Although three or four views might be taken to cover all the breast tissue, no additional codes would be assigned for screening studies.

In some cases, a primary-care physician or gynecologist will refer a patient for diagnostic mammography if she has presented with symptoms uncovered during a breast self-examination or a clinical exam. Diagnostic mammography is coded with 76090 (mammography; unilateral) or 76091 (mammography; bilateral). The diagnosis code would reflect the signs and symptoms that prompted the referral (i.e., 611.71, mastodynia, pain in breast; or 611.72, lump or mass in breast).

Special Circumstances Affecting Mammography

A number of circumstances may make coders wonder if a mammogram should be reported as a screening or diagnostic exam, Hall says. Among the most common are:

1. Women with a history of breast cancer. Although many local carriers follow the lead of the Health Care Financing Administration (HCFA) and allow physicians the discretion to order diagnostic mammograms for women who have a personal history of breast cancer (V10.3), others are more restrictive.

April Brazinsky, CCS, coding specialist for the Community Hospital of the Monterey Peninsula in Monterey, Calif., for instance, says her local carrier requires that mammograms be reported as screening unless the patient exhibits current cancer symptoms. If the patient is due for her annual mammogram while undergoing chemotherapy, the carrier considers that the patient has current symptoms, and the mammogram is diagnostic. When the treatment has ended, however, 76092 is assigned.

Other areas of the country follow different guidelines. Radiologists in Connecticut may bill mammography as diagnostic for five years after cancer treatment, for example, while Washington state allows it for three years. Coders should check with their local carriers for current requirements.

2. Postmastectomy patients. Generally, Hall notes, if the patient is free from symptoms, the mammogram would be considered screening, subject to local payer guidelines. The American Medical Association (AMA) and some carriers, however, require that coders append modifier -52 (reduced services) for patients who are having the remaining breast evaluated because screening mammography is defined as bilateral.

3. History of benign breast disease. Determining whether to assign diagnostic or screening mammography codes to women who have a history of benign breast disease like fibrocystic breast disease (610.1) depends on their current clinical status. If a patient is symptomatic, a diagnostic mammogram would be reported. If the patient was previously diagnosed, but is now free from symptoms, a screening study would be more appropriate.

Mammogram Conversions

Often, radiologist will interpret films from a screening mammogram, identify an abnormality and order additional breast images, Hall points out. The radiologist is allowed to make this decision based on medical necessity without the input of the referring physician.

If the radiologist orders the additional films on the same day of service, the screening exam becomes a diagnostic procedure, she says. Coders would assign only the appropriate diagnostic mammography code, and not the screening code.

In addition, radiology coders may assign the -GH modifier a reporting mechanism used to indicate that the diagnostic mammogram was converted from a screening study on the same date of service. This modifier was established by HCFA for the purpose of collecting data on the number of these converted mammograms, Hall adds. Use of the -GH modifier follows Medicare reporting procedures and is described in the AMAs HCPCS manual.

Although the -GH modifier should be appended to Medicare claims, coders have a choice with non-Medicare patients. If practice policy is to minimize the use of modifiers, coders may choose not to assign it. Other practices add it to all claims to maintain consistency.

In some cases, the radiologists order for additional films does not occur on the same date of service, Hall says. Some imaging centers or radiology departments have their technologists perform the screening and hold the results for the radiologist to interpret later. The patient has been sent home before the radiologist views the films and must be called back the next day for another mammogram.

When the diagnostic mammogram occurs on a different day from the screening mammogram, both services may be reported 76092 for one day, and 76090 or 76091 for the subsequent day. Although it is acceptable to charge for both, some radiologists opt to forego billing the screening exam and only report the diagnostic mammogram.

Diagnostic Breast Ultrasound

An ultrasound of the breast would be ordered if mammography has uncovered an abnormality and the radiologist requires more information. Generally speaking, breast ultrasound is used to determine whether the lump or mass is a solid tumor or a cyst filled with fluid, Hall explains. Ultrasound will not diagnose cancer. But if it indicates that the mass is solid, the radiologist will know further diagnostic testing is required.

The correct code for a breast ultrasound is 76645 (echography, breast[s] [unilateral or bilateral], B-scan and/or real time with image documentation). Coders should note that this code might be assigned only once, even if both breasts are viewed. Even though the description clearly states 76645 is to be assigned for one or both breasts, many coders try to report it twice.

Now, orders for a breast ultrasound must be generated by the treating physician, not by the radiologist.

Needle Core and Image-guided Breast Biopsies

Coders may be confused about how to report various biopsy techniques. Traditionally, coding biopsies were straightforward because they were performed on palpable lesions and no guidance was used to assist the radiologist. Radiology practices would assign code 19100* (biopsy of breast, needle core [separate procedure]) because it described the process of inserting a needle and extracting pieces of tissue for further examination and testing.

Surgeons, on the other hand, used an open surgical incision to remove suspected tissue. They typically assigned 19101 (biopsy of breast, incisional).

But the recent advent of stereotactic instruments has made it possible for radiologists to biopsy small, nonpalpable lesions for definitive diagnosis. Physician time increased dramatically, and the costs of the technology related to the procedure also rose. CPT code 19100 no longer represents fair compensation for the procedure.

In response to this, HCFA modified its breast biopsy reporting guidelines and advised radiology practices that 19101 should be used to report image-guided biopsies on nonpalpable lesions. This is confusing to a lot of radiology coders because 19101 refers to an incision, says Hall. Of course, the radiologist does not use an incision during a breast biopsy. This code, however, does reflect accurately the level of work involved. So even if the language doesnt fit, this is the code that should be reported.

She adds that the two key components coders should keep in mind are:

1. Whether the lesion is palpable; and
2. Whether guidance was used.

If both of these elements appear in the report, 19101 should be assigned for the biopsy regardless of the technique or surgical devise used. Hall adds that coders should be aware that 19101 carries a 10-day global surgical period.

If stereotactic guidance is used during the breast biopsy, radiological supervision and interpretation (S&I) code 76095 (stereotactic localization for breast biopsy, each lesion, radiological supervision and interpretation) should be assigned in addition to 19101. If ultrasound guidance is used, 76942 (ultrasound guidance for needle biopsy, radiological supervision and interpretation) should be added.

Code 19100 should continue to be assigned for needle core biopsies of palpable lesions.

Codes 19100, 19101 and 76095 are assigned based on the number of lesions biopsied, not the number of passes the sampling device makes on each lesion. In addition, Hall says, if x-rays are taken of the biopsy samples to make sure the specimens include tissue from the abnormality, 76098 (radiological examination, surgical specimen) would be coded in addition to the procedure and S&I code.

On occasion, all suspected tissue would be excised during a stereotactic breast biopsy. Coders may be tempted to add 19120 (excision of cyst, fibroadenoma, or other benign or malignant tumor aberrant breast tissue, duct lesion, or nipple or areolar lesion [except 19140], male or female, one or more lesions) to the procedure code in this situation, she notes, but this would be inappropriate. HCFA says that 19101 includes instances where all mammographic evidence of the abnormality is removed.

Wire Localization Placement

Often, at the conclusion of a biopsy, radiologists will place a titanium clip or wire to mark the biopsy area in case follow-up surgery or localized radiation is needed. Until recently, preferred coding for this service was 19290 (preoperative placement of needle localization wire, breast). Use of this code is clouded, and coding experts hope it will be clarified with the addition of a new code in 2001.

In the meantime, coders are advised that it would be wise to report clip or wire placement with 19499 (unlisted procedure, breast).

Although ultrasound guidance is often used during clip or wire placement, coders would not report 76942 because this service is assumed to be covered by the S&I code that accompanied the biopsy.