October Rise in Breast Health Services Will Challenge Coders and Increase Payment
Published on Fri Sep 01, 2000
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 [...]
