Radiology Coding Alert

Question: I have two unilateral mammogram scenarios I am working on. The first involves a patient who requests that only one side is imaged, despite have two intact breasts. The second scenario involves a patient who is missing one breast following a traumatic event, but has no history of a mastectomy. What’s the CPT^® coding for these examples?

Delaware Subscriber

Answer: Despite the differing clinical encounters, the coding for both scenarios will be the same. Regardless of the clinical reasoning for performing a unilateral mammogram, you will still append modifier 52 (Reduced Services) to 77067 (Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed) in both instances.

Outside of the coding, your biggest consideration has to do with payer guidelines when submitting 77047 with modifier 52 appended. Medicare and some commercial payers are notorious for denying these claims, so it’s in your best interest to confirm whether the payer requires additional information and/or modifiers. For instance, some payers request that in addition to modifier 52, you also append modifiers LT (Left Side) or RT (Right Side) to indicate laterality. Other payers may request that the you submit the claim on paper in order to justify the use of modifier 52.