Radiology Coding Alert

Question: Can we bill separately for an E/M service and a diagnostic mammogram on the same day?

RCA Subscriber

Answer: Whether you can charge separately for an E/M service and a diagnostic mammography really depends on whether the radiologist's documentation meets all of the requirements for the E/M service and that the radiologist is not "double-dipping," considering the time he spends discussing the results of the mammography with the patient as part of the E/M service.

The components of a screening mammogram include the mammogram itself, interpretation and report, and the communication of the results to the patient. The components of a diagnostic mammogram include a brief history identifying the reason for the exam, palpation of the breasts if indicated, the mammogram itself, interpretation and report, and the communication of the results to the patient.

If the radiologist performs a diagnostic mammogram, which includes a review of previous mammogram, discussion of the test results, dictation of the report, etc., and he also performs an evaluation of the patient for an entirely separate problem, you can bill for each service separately. Make sure the documentation clearly shows that the office visit meets the history, examination and decision-making requirements and that this documentation is reported separately from the documentation of the time spent performing the mammogram.

If your physician does meet the requirements for reporting both services, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service.

Answers to You Be the Coder and Reader Questions provided by Mary Session, CPC, billing supervisor for Associated Billing Services in Phoenix; Stacy J. Hardy, CPC, coding specialist with Sierra Vista Diagnostics in Arizona; and Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based firm.