Radiology Coding Alert

Question: If the radiology department routinely does extra mammogram views on asymptomatic patients, does that mean the exam is diagnostic even if the patient presents for screening?

Codify Subscriber

Answer: Routine performance of extra views is not sufficient to support coding a diagnostic mammogram rather than a screening.

To ensure proper coding, review the payer’s definitions of screening and diagnostic mammography. Also review the rules for when the radiologist may convert a screening exam to diagnostic without an additional physician order.

Diagnostic:  For Medicare, “diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease,” according to the Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.4.

Screening: “A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease,” the mammography NCD states.

Order requirements: Diagnostic exams require a physician’s order. Medicare will cover screening mammograms even without a physician order for women who meet age and frequency requirements, according to the Medicare Claims Processing Manual (MCPM), Chapter 18, Section 20.A.

If the screening reveals a potentialproblem, Medicare allows radiologists to orderadditional mammography views “while a beneficiary is still at the facility for the screening exam,” states the MCPM, Chapter 18, Section 20.6.A. You should report both screening and diagnostic codes. Append GG (Performance and payment of a screeningmammogram and diagnostic mammogram on the samepatient, same day) to the diagnostic code. Medicare will pay for both the screening and diagnostic exams in this case.