Radiology Coding Alert

A Florida radiology group agreed to pay $2.53 million after being charged with billing Medicare falsely, including reporting screening mammograms as diagnostic procedures. Learn one way to avoid this costly mistake.

Remembering modifiers and knowing when documentation is necessary for Medicare reimbursement can be a tricky business with dangerous consequences. Here's how to use modifier -GG to code same-day screening and diagnostic mammograms performed in a single patient encounter.

Use Modifier -GG in the Proper Situation
 
Problem: A female patient covered by Medicare comes in for her annual screening mammogram. The radiologist detects an abnormality and determines that a diagnostic mammogram is necessary. He completes this procedure on the same day. How do you code this? What documentation is necessary for reimbursement for these services?
 
Solution: Modifier -GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) addresses this problem for all services performed after Jan. 1, 2002. CMS intends for you to report modifier -GG when a diagnostic exam is ordered and performed for a patient who has undergone a screening and is still at the facility, says Jackie Miller, RHIA, CPC, senior consultant for Coding Strategies Inc. in Powder Springs, Ga. You should never append -GG if a physician sends a patient home after a screening exam and then calls her back for diagnostic services on a different date.
 
Modifier -GG tells the insurance carrier "that you really thought you found something, and you wanted to investigate further," says Cheryl Schad, BA, CPCM, CPC, owner of Schad Medical Management, a medical reimbursement consulting firm in New Jersey. Modifier -GG also tells the carrier that the choice to do the diagnostic was legitimate and not just an attempt to get more money. 
 
Medicare musts: For Medicare to reimburse you for each mammogram, you should report both the screening (76092, Screening mammography, bilateral [two view film study of each breast]) and diagnostic mammogram (either 76090, Mammography; unilateral or 76091, ... bilateral). You append modifier -GG to the diagnostic code. The same is true if the radiologist uses digital imaging. You report the screening code (G0202, Screening mammography, producing direct digital image, bilateral, all views) and append -GG to the diagnostic code (G0204, Diagnostic mammography, producing direct digital image, bilateral, all views or G0206, ... unilateral ...).
 
Medicare Transmittal 1724 announced the addition of modifier -GG and states that the modifier should be used for tracking.
 
Remember: Medicare requires HCPCS Level II codes when you report digital mammograms, and non-Medicare insurers may not accept these codes. Consult with private payers before submitting claims for these services using HCPCS Codes or modifier -GG.
 
Claim form how-to: When submitting claims to Medicare or to private payers that advocate using modifier -GG, put the screening code in the primary position on the claim form, and link it to the screening diagnosis code V76.12 (Other screening mammogram) to indicate that the radiologist performed a mammogram for a patient who presented with no complaints.
 
You list the diagnostic mammogram second on the claim and link it either to ICD-9 code 793.80 (Abnormal mammogram, unspecified) or to a more specific code, if possible. Medicare covers diagnostic mammograms for patients whose same-day screening reveals a problem the radiologist thinks needs further study, such as suspicion of a breast neoplasm.

Know When Orders Are Necessary

A radiologist does not need an additional order from the treating physician to perform the diagnostic mammogram when it is done on the same day as a screening, Schad says. However, she says the abnormal finding in the screening mammogram that justifies the diagnostic "would have to be documented in the interpretation of the screening mammography and the diagnostic mammography so that you can see a trail." Schad stresses that "a coder's going to look for it, and an auditor is going to look for it."
 
"The Medicare rules for ordering of diagnostic tests apply only in the non-hospital setting," Miller adds.
 
Caution: If a diagnostic ultrasound is performed in the place of a diagnostic mammogram, you should not append modifier -GG, says Jeff Fulkerson, BA, CPC, CMC, senior certified coder for the department of radiology at The Emory Clinic in Atlanta.
 
You should only add modifier -GG to diagnostic mammogram codes. If the radiologist thinks that any test beyond the diagnostic mammogram (e.g., ultrasound, MRI) is necessary, he must get an order from the treating physician, Schad says. 

Lesson: The importance of proper documentation of orders was revealed in the recent audit of Radiology Regional Center (RRC) in Florida. The center faced penalties of $15,000 per false claim due to a lack of medical-necessity documentation. Auditors deemed many of RRC's procedures medically unnecessary because no written documentation existed to prove that additional imaging services were needed for individual patients. RRC's administrator argued that verbal orders were given for the procedures, in the place of written documentation. Remember, an auditor probably won't find this acceptable. 
 
Encourage your office to foster an open-door policy on compliance issues, Fulkerson says, so you can report any problems in the documentation chain affecting your job. Fulkerson insists you need to believe that if you were sitting across the table from an auditor, you would be able to confidently explain how you came up with the code and why it is the best choice.