But putting all of the latest codes and modifiers aside, to be able to code screening-turned-diagnostic mammograms without digital imaging, you must first be able to identify and differentiate 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. Although mammogram screenings and diagnostic mammograms are similar procedures, they are very different in the eyes of payers.
A screening mammogram, 76092 (Screening mammography, bilateral [two view film study of each breast]), is considered a routine procedure performed for asymptomatic patients for the purpose of early detection of breast cancer.
On the other hand, diagnostic mammograms, 76090 (Mammography; unilateral) and 76091 ( bilateral), are mammograms performed for a patient who presents with signs or symptoms of breast disease, i.e., nipple discharge, a mass, tenderness or skin changes. And with diagnosis codes that support medical necessity for the diagnostic mammography, there are no restrictions on its frequency of billing. Don't Make Assumptions About Women With Implants One of the trickier cases to identify, and one that is becoming more and more prevalent, is whether mammograms for women with breast implants should be considered screening or diagnostic. We know that women with breast implants may be at a higher risk for breast cancer, Hardy says, but that doesn't mean we can automatically assume a carrier will cover a diagnostic mammogram just because the patient has had implants. "According to Medicare, V76.11, the high-risk screening diagnosis code, is too vague to substantiate a diagnostic mammogram," and you'll be hard-pressed to find a more-applicable code, Hardy warns. Don't use implants alone as justification for a diagnostic mammogram, especially for a Medicare patient, she advises coders. However, if the implants were placed after a mastectomy for breast cancer, Hardy says, it's another ballgame. The personal history of cancer is typically enough to substantiate reporting the diagnostic mammogram; just be sure your carrier doesn't restrict the length of time between the cancer treatment and any recurring symptoms that your patient's case does not meet. Remember: There's More Than the 70000s New digital imaging equipment has spurred the addition of temporary HCPCS Codes for diagnostic and screening mammograms performed with digital imaging, Hardy says. Don't bill these codes unless you are sure your facility has and uses the special equipment. For Medicare patients who undergo a screening mammography performed with digital [...]