Radiology Coding Alert

Question: My radiologists want to bill a diagnostic mammogram for a screening because the patient has breast implants. Medicare will not pay a diagnostic with a screening diagnosis. How should I bill this?

Virginia Subscriber

Answer: Careful -- the presence of implants does not automatically justify coding a diagnostic mammogram.

Although women with implants require at least one additional view to adequately check for abnormalities, this alone does not qualify as "diagnostic" under Medicare's rules.

Screening: A screening mammogram is "a radiologic procedure provided to an asymptomatic woman for the purpose of early detection of breast cancer," according to the Medicare Benefit Policy Manual (MBPM), chapter 15, section 280.3. As long as women meet age and frequency requirements, Medicare will cover screening mammograms even without a physician order.

So if the patient requested the mammogram herself or an ordering physician sent her for a screening mammogram, and the radiologist did not see something on review that required further views on the same date, you should report a screening mammogram. Use the appropriate code, such as 77057 (Screening mammography, bilateral [2-view film study of each breast]). You should report the appropriate screening diagnosis code as well:

• V76.11 -- Screening mammogram for high-risk patient

• V76.12 --Other screening mammogram.

Should you assume that a breast implant makes the patient high risk (V76.11)? Previous Medicare policy does not support this. The MBPM shows that in 1997, when providers had to indicate the patient's high-risk category, the supporting diagnoses were:

• V10.3 -- Personal history of malignant neoplasm; breast

• V16.3 -- Family history of malignant neoplasm; breast

• V15.89-- Other specified personal history presenting hazards to health; other.

And the "other specified personal history" included not giving birth prior to age 30 or a personal history of biopsy-proven benign breast disease.

Diagnostic: Medicare covers diagnostic mammography when a physician orders the diagnostic service for a patient with signs and symptoms supporting medical necessity or a personal history or other factors the physician decides merit a diagnostic service, as stated in Medicare Claims Processing Manual, chapter 18, section 20.B.

Note: Medicare does allow radiologists to order additional mammography views when a screening mammography shows a potential problem. You would code these additional views as a diagnostic mammogram and append modifier GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day). If the implants cause poor visibility or other problems this qualifies as a potential problem -- and a reason for the radiologist to perform diagnostic views on the same date -- for many payers.