Radiology Coding Alert

Question: When we perform a mammogram of the remaining breast on a patient who had a mastectomy (one breast), how should we code this?


Florida Subscriber

Answer: Chances are your physician believes that a post-mastectomy patient should always have a diagnostic rather than a screening mammogram. The secret is knowing what your payer wants and making sure the referring physician's order is consistent with payer policy.

Many Medicare carriers will cover a diagnostic mammogram for a patient who had a mastectomy for breast cancer.

Example: First Coast (Florida) states in its local coverage determination that a unilateral diagnostic mammogram is medically necessary in a number of situations, including "when a patient has had a unilateral total mastectomy." For a unilateral diagnostic mammogram, you typically report 76090 (Mammography; unilateral).

Problem: Not all payers agree with this stance. HealthNow of New York maintains that although a diagnostic may make sense "in cases of a personal history of malignancy and in cases of benign biopsy-proven breast disease," once the patient achieves clinical stability, you should return to using a screening mammogram as the first step. Payers with similar policies typically ask you to report 76092 (Screening mammography, bilateral [two view film study of each breast]) and append modifier -52 (Reduced services) to indicate you only tested one breast.

The answers for You Be the Coder and Reader Questions were reviewed by Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga.; and Gary S. Dorfman, MD, FACR, FSIR.