Radiology Coding Alert

Question: Insurance companies are not paying for extra views (Ellund technique) we take during diagnostic mammograms that are taken in this office for patients with breast implants. I write in box 19 of the HCFA 1500 form that a total of eight views are taken. Medicare accepts this when I use 76091 (mammography, bilateral) with modifier -GH (diagnostic mammogram converted from screening mammogram on same day), but most other insurance companies will not accept these modifiers. I have been using modifier -22 (unusual procedural services) for other payers, but I am still getting denials for additional payment. Should I send a report?

California Subscriber

Answer: The reason you are having difficulty with payers is that the diagnostic mammogram codes cover whatever number and type of views are included in the practice protocol. There is no limiting provision on the number of films or views obtained for these codes. The same is true when you perform a screening mammogram (76092, screening mammography, bilateral [two view film study of each breast]) on an extremely large-breasted woman, and three or four films are needed to obtain the appropriate views for a single breast. Many Medicare carriers specifically state that a screening mammogram is a minimum of two views of each breast.

The -GH modifier is specific to Medicare only and indicates that a screening mammogram was converted to a diagnostic, based upon a clinical finding. The -GH modifier may not apply to any commercial carrier. In addition, Medicare is likely allowing the same amount with or without the modifier. Sending the reports will not improve payment because the codes have no predetermined number or type of views.

Note: Screening mammograms cannot be converted to a diagnostic study unless there is a documented clinical finding and the radiologist requests additional views to further define the abnormality. Implants are not considered a clinical condition that justifies performing a diagnostic mammogram in place of a screening study.