Radiology Coding Alert

Question: A general practitioner referred their patient to our radiology practice after they felt a lump in her breast. The order from her GP requested a screening mammography of the right breast. After the procedure, the radiologist found an abnormal growth in the breast tissue and ordered a diagnostic mammography for the same day.

Do I only need to use the appropriate CPT^® codes to report the visit?

New York Subscriber

Answer: In addition to the applicable CPT^® codes, you’ll want to use Z12.31 (Encounter for screening mammogram for malignant neoplasm of breast) as the reason for the visit. According to section I.C.21.5.c of the ICD-10-CM guidelines, “A screening code may be a first-listed code if the reason for the visit is specifically the screening exam.”

Following the ICD-10-CM code, you’ll use CPT^® code 77067 (Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed) to document the screening mammography. Additionally, if the radiologist performed the procedure only on the right breast as the order indicated in your question, then you’ll append the code with modifier 52 (Reduced Services). Then, you’ll use either 77065 (Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral) or 77066 (…; bilateral) if the physician performed the diagnostic mammography on the right breast or both breasts. Lastly, if the physician makes a diagnosis during the visit, you’ll add the applicable ICD-10-CM code at the end.