Radiology Coding Alert

Question: My understanding is that a routine mammogram is only for bilateral services. I also believe we cannot use a modifier for a routine mammogram (such as G0202-RT). So how should I code this case? The patient is status post left breast mastectomy. She presents herself to our office for a yearly mammogram on her right breast. Do we code this as a unilateral diagnostic, or do we code this as a routine screening?

Answer: The general advice is that you should (a) code based on whether the ordering doctor called it screening or diagnostic (keeping in mind that Medicare doesn't require an order for screening) and (b) make sure the ordering doctor's understanding of screening/diagnostic matches the payer's.

If you're coding for someone under NGS Medicare, New York's carrier, there are a couple of resources you can look to for information. They show that for NGS Medicare patients, your case could be either a screening or diagnostic, depending on the ordering physician's view (payer policies do vary on this, so check individual policies).

LCD: The first resource to check is the local coverage determination (LCD) at http://apps.ngsmedicare.com/lcd/LCD_L26890.htm. It says, "Diagnostic mammography is indicated when: ...

• there is short interval follow-up (at six month intervals, for 2 years) necessary for unresolved clinical/ radiographic concerns;
• A personal history of breast malignancy exists. Once clinical and mammographic stability has been established, the routine use of diagnostic mammography over screening mammography is not warranted."

Translation: The LCD seems to suggest that even patients with a history of breast cancer can return to "screenings."

Second is an article connected to the LCD that instructs its providers to append modifier 52 (Reduced services) to screening mammogram codes if they need to indicate a unilateral service. The article is at http://apps.ngsmedicare.com/sia/ARTICLE_A48362.htm.

The NGS article states: "Screening mammography codes 77057 [Screening mammography, bilateral (2-view film study of each breast)] or G0202 [Screening mammography, producing direct digital image, bilateral, all views] and 77052 [Computer-aided detection ...; screening mammography (List separately in addition to code for primary procedure)] should be reported whether the mammography is performed unilaterally or bilaterally. The modifier 52 (Reduced services) should be appended to the CPT/HCPCS codes when it's performed unilaterally. When modifier 52 is appended to the screening mammography codes 77057 or G0202 and 77052, it would be assumed that the service rendered was a unilateral mammography. The unilateral mammography would be paid at a reduced rate."