Radiology Coding Alert

Coding for screening-turned-diagnostic mammograms has come a long way since the days before modifier -GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day).

But putting all of the latest codes and modifiers aside, to be able to code screening-turned-diagnostic mammograms without digital imaging, you must first be able to identify and differentiate between the two types.

Just because a woman has a family history of breast cancer, you can't classify the mammogram as "diagnostic," says Stacy J. Hardy, CPC, coding specialist with Sierra Vista Diagnostics in Arizona. Although mammogram screenings and diagnostic mammograms are similar procedures, they are very different in the eyes of payers.

A screening mammogram, 76092 (Screening mammography, bilateral [two view film study of each breast]), is considered a routine procedure performed for asymptomatic patients for the purpose of early detection of breast cancer.

On the other hand, diagnostic mammograms, 76090 (Mammography; unilateral) and 76091 ( bilateral), are mammograms performed for a patient who presents with signs or symptoms of breast disease, i.e., nipple discharge, a mass, tenderness or skin changes. And with diagnosis codes that support medical necessity for the diagnostic mammography, there are no restrictions on its frequency of billing.

Don't Make Assumptions About Women With Implants

One of the trickier cases to identify, and one that is becoming more and more prevalent, is whether mammograms for women with breast implants should be considered screening or diagnostic.

We know that women with breast implants may be at a higher risk for breast cancer, Hardy says, but that doesn't mean we can automatically assume a carrier will cover a diagnostic mammogram just because the patient has had implants. "According to Medicare, V76.11, the high-risk screening diagnosis code, is too vague to substantiate a diagnostic mammogram," and you'll be hard-pressed to find a more-applicable code, Hardy warns. Don't use implants alone as justification for a diagnostic mammogram, especially for a Medicare patient, she advises coders.

However, if the implants were placed after a mastectomy for breast cancer, Hardy says, it's another ballgame. The personal history of cancer is typically enough to substantiate reporting the diagnostic mammogram; just be sure your carrier doesn't restrict the length of time between the cancer treatment and any recurring symptoms that your patient's case does not meet.

Remember: There's More Than the 70000s

New digital imaging equipment has spurred the addition of temporary HCPCS Codes for diagnostic and screening mammograms performed with digital imaging, Hardy says. Don't bill these codes unless you are sure your facility has and uses the special equipment.

For Medicare patients who undergo a screening mammography performed with digital imaging, report temporary HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views). For bilateral diagnostic mammograms performed with digital imaging, report G0204 (Diagnostic mammography, producing direct digital image, bilateral, all views), and for unilateral diagnostic mammograms with digital imaging, report G0206 (Diagnostic mammography, producing direct digital image, unilateral, all views).

Also, G0236 (Digitization of film radiographic images with computer analysis for lesion detection, or computer analysis of digital mammogram for lesion detection, and further physician review for interpretation, diagnostic mammography [list separately in addition to code for primary procedure]) is an additional digital imaging code. Contact your carrier for specific coverage information on the aforementioned G codes.

CPT includes add-on code +76085 (Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, mammography [list separately in addition to code for primary procedure]) to define digitization for those payers that do not accept the HCPCS G codes.

Take the Quiz

Test your ability to determine whether a screening or diagnostic mammogram should be coded in these clinical scenarios:
Scenario 1: A 40-year-old woman notices a lump in her breast six months after her last screening. The diagnosis code assigned is 611.72 (Signs and symptoms in breast, lump or mass in breast).
Scenario 2: A 52-year-old woman presents for a routine screening that reveals a mass. Adiagnostic procedure is ordered for later that day.
Scenario 3: A patient whose cancer is in remission presents for a diagnostic mammogram.

Answer 1: Diagnostic. Other than symptoms of cancer, there is no diagnosis code available to substantiate medical necessity for a diagnostic mammogram. However, Medicare and other payers will reimburse for diagnostic mammograms based on specific symptoms that indicate the potential for breast cancer, including 611.72. Because the patient presented with one mass limited to one breast, 76090 is the proper CPT code to represent the procedure, when a unilateral diagnostic mammogram is ordered by the physician.

Answer 2: Screening and diagnostic. This is a tricky one. When a routine screening shows an abnormality and requires a diagnostic mammogram on the same day, both the code for the screening mammogram and the code for the diagnostic mammogram should be reported.

Most Medicare carriers advise radiology coders to sequence the screening code, 76092, as the primary procedure performed and link it to the appropriate V code, most likely V76.12 (Special screening for malignant neoplasms, breast, other screening mammogram).

Sequence the diagnostic mammogram, 76090 (or 76091 if the attending physician orders a bilateral study), second and link it to the diagnosis code 611.72, or a more specific finding of the exam. You should report the unilateral diagnostic mammogram code because there was no mention of multiple masses. If, and only if, the patient is covered under Medicare, append modifier -GG to the diagnostic mammogram code. Modifier -GG should only be used for Medicare Part B claims, not for the hospital facility component.

Answer 3: Diagnostic. When a patient whose cancer is in remission comes in for a follow-up diagnostic mammogram, the correct diagnosis code is V10.3 (Personal history of breast cancer). Either screening or diagnostic mammograms are considered an integral component of managing aftercare for patients who have been successfully treated for cancer, and the decision on which test to order rests with the attending physician.