A fine line separates screening and diagnostic mammogram tests, and you had better not cross it. Though similar procedures, they are very different in the eyes of payers even for mammograms on women who have breast implants.
When you're coding, you should separate screening and diagnostic mammograms in the same way your payer will separate them.
Screening mammograms, 76092 (Screening mammography, bilateral [two-view film study of each breast]) are routine procedures performed to detect breast cancer early in asymptomatic patients. The physician doesn't usually meet face-to-face with the patient receiving a screening mammography, says Mary Session, CPC, billing supervisor for Associated Billing Services in Phoenix. The technician performs the mammogram, and the physician doesn't usually read the film until the end of the day, she says.
Diagnostic mammograms, 76090 (Mammography; unilateral) and 76091 (... bilateral), on the other hand, are procedures performed for patients with signs or symptoms of breast disease nipple discharge, mass development, tenderness or skin changes. Combined with diagnosis codes that support medical necessity, diagnostic mammography codes have no restrictions on frequency of billing, Session says.
You must learn how to distinguish 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. To brush up on the basics for differentiating screening and diagnostic mammograms, look for "Get Paid What You Deserve: Don't Confuse Screenings With Diagnostic Mammograms" in the June 2002 Oncology Coding Alert.
Read below to pump up payment for one particular mammogram case tests on patients with breast implants.
Don't Make Assumptions About Women With Implants
One of the trickier mammogram cases to code and one that's becoming more and more prevalent is the mammogram for women with breast implants.
Don't use the presence of implants alone as a justification for the diagnostic mammography code, especially for a Medicare patient, Hardy advises coders. According to CMS, patients with breast implants do not automatically qualify for diagnostic mammograms.
That means the same breast cancer screening guidelines that apply to women who don't have implants, apply to those who do.
If there are extra films, don't automatically select a code other than 76092. Certain screening mammograms, including those for patients with breast implants, may require more than the standard two-view exposure of each breast for screening mammograms, CMS states. If this is the case, Medicare instructs coders to report ICD-9 code 996.54 (Mechanical complications due to breast prosthesis) to substantiate taking the extra films. You should still report the screening mammography code.
You're dealing with another ball game, however, if the patient had implants placed after a mastectomy for breast cancer, [...]