Radiology Coding Alert

1 tip helps you choose between high-risk and standard screenings with ease

Work your way through this mammogram report, and you'll quickly learn how to take advantage of Medicare's detailed mammogram instructions to create clean claims.

Challenge: Analyze the following report, offered in The Coding Institute audioconference "Foolproof Radiology Coding Tips," presented by Stacie L. Buck, R SHIA, CCS-P, LHRM, RCC, vice president of Southeast Radiology Management. Then check your answers against the experts' below.
 
Procedure: Screening Mammography Bilateral

Indication: Routine screening, family history of breast cancer--sister

Findings: Bilateral craniocaudal and mediolateral oblique views were obtained. Computer-aided diagnosis by R2 software system. Since the prior study, the breast parenchymal pattern with mild asymmetry and nodulation appears stable. Axillary lymph nodes are present. 

Recommendation: Yearly surveillance is suggested.

Birads Category: 2--Benign

Step 1. Choose Your ICD-9 Codes

From the documentation, you know that the patient received a routine screening mammogram and has a sister with a history of breast cancer. Both of these facts are important to choosing your diagnosis codes.

When the patient has a screening mammogram, you need to choose between high-risk screening code V76.11 (Screening mammogram for high-risk patient) and screening code V76.12 (Other screening mammogram).

CMS considers the following patients to be high-risk, Buck says (see www.cms.hhs.gov/Transmittals/Downloads/R426CP.pdf for the exact CMS language):

• personal history of breast cancer (V10.3, Personal history of malignant neoplasm; breast)

• family history of breast cancer (V16.3, Family history of malignant neoplasm; breast)

• Mother
• Sister
• Daughter
• no childbirth prior to age 30 (V15.89, Other specified personal history presenting hazards to health; other)
• personal history of biopsy-proven benign breast disease  (V15.89).

The example patient has a sister with a breast cancer history, which CMS lists as a high-risk factor, so you should consider the example mammogram a high-risk screening mammogram.

What to do: Report V76.11 first, and then report V16.3 to explain the reason for choosing the high-risk screening code.

Step 2: Be Careful With CPT Codes

Your documentation indicates that the patient received a screening mammogram, pointing to 77057 (Screening mammography, bilateral [2-view film study of each breast]) as the appropriate code.

Providers order these mammograms for asymptomatic females who haven't manifested any clinical signs, symptoms, or physical findings of breast cancer, Buck points out.

Screening mammography must be at least a two-view exposure of each breast:

1. cranio-caudal (CC)

2. medial lateral oblique (MLO).

See Medicare National Coverage Determinations Manual Chapter 1, Part 4, Section 220.4 (Mammograms) for the exact CMS language, www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf.

Your documentation indicates the required views and includes an interpretation of them, so 77057 is the appropriate code.

Don't miss: Add-on code +77052 (Computer-aided detection [computer algorithm analysis of digital image data for lesion detection] with further physician review for interpretation with or without digitization of film radiographic images; screening mammography [list separately in addition to code for primary procedure]) describes an added computer-aided detection service providers may use for screening mammograms.

For you to report this code, the radiology report must document computer-aided diagnosis use for the exam, says Barbara Rutigliano, MS, RT(R), CPC, RCC, coding manager with Jefferson Radiology in East Hartford, Conn.

The sample report documentation indicates "computer-aided diagnosis by R2 software system."

What to do: Report 77057 and 77052 for the documented procedures.