Reader Question:
Mammogram for Fibrocystic Syndrome Patient
Published on Sat Jan 01, 2000
Question: If a patient has fibrocystic syndrome, is a mammogram considered diagnostic or screening?
Anonymous Ark. Subscriber
Answer: It depends on whether or not the patient is currently symptomatic, according to a review of local Medicare policies conducted by Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.
As a general rule, a screening mammogram (76092screening mammography, bilateral [two view film study of each breast]) is furnished to a patient without signs or symptoms of breast disease. On the other hand, a diagnostic mammogram (76090mammography, unilateral or 76091bilateral) is typically conducted on a man or woman with signs or symptoms of breast disease, a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease.
However, because of the nature of fibrocystic breast syndrome, specific coding guidelines apply. According to Medicare policy, a diagnosis of fibrocystic breast disease (610.1) does not in and of itself indicate medical necessity for a diagnostic mammogram. Routine exams should be coded as screening mammograms. However, a patient diagnosed with fibrocystic disease and presenting with suspicious changes, signs or symptoms would be eligible for a diagnostic mammogram.
Coding Example #1: Patient presents with an order for a screening mammogram with a previous diagnosis of fibrocystic disease, no current symptoms. Correct coding would be to use 76092, with a primary diagnosis code of V76.12 (other screening mammogram) and secondary diagnosis code of 610.1.
Coding Example #2: Patient presents with an order for a screening mammogram with a diagnosis of fibrocystic disease. When questioned, it is determined that the patient went to her doctor because she was experiencing pain in the right breast and had found a new lump while showering. The mammography facility calls the attending physician and gets a corrected verbal order for a diagnostic. (A verbal order must be signed within 48 hours, per certification requirements.)
Coding professionals would assign diagnostic code 610.1 and service code 76090
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