Radiology Coding Alert

Question: A patient has a history of a unilateral mastectomy for cancer and has remained asymptomatic in the other breast for a number of years. She has been getting annual unilateral mammogram ordered as a diagnostic exam. Is there a time span for which she can now get her annual mammogram as a routine/screening unilateral rather than a diagnostic? Or should we always consider this scenario diagnostic? Or should we always consider it a routine screening?

Texas Subscriber

Answer: You should check with your payer for a precise answer to this question.

The ordering physician should specify whether the mammogram is screening or diagnostic, but she should understand how the payer defines those terms.

Many payers, such as Noridian and Empire, do allow you to report a unilateral screening mammogram by appending modifier 52 (Reduced services) to the screening mammogram code, such as 77057-(Screening mammography,-bilateral [two-view film study-of each breast]). This policy suggests that not every postmast- ectomy mammogram is diagnostic.

Other payers, however, may consider diagnostic mammograms medically necessary for any patient with a breast cancer history.