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screening and diagnostic mammos

Carolyn Posted Tue 21st of May, 2013 14:09:27 PM

if the radiologist documents "spot compression (s) taken in the report for a screening mammography can we bill both a screening mammo as well as a diagnostic unilateral?

SuperCoder Answered Tue 21st of May, 2013 14:31:52 PM

Patients who are asymptomatic and request a mammogram are categorized as screening. For Medicare, and many other payers, these patients do not require a physician order and may self refer to a mammography center. Report 77057 for screening mammograms with a two view bilateral study. Additional views are seldom needed, but when they are performed, do not change the code selection or billing units.

In lieu of 77057, Medicare requires the use of code G0202 to report screening mammograms. If only one breast is screened, append modifier 52.

Patients who have a history of breast disease, whether malignant or biopsy proven benign, fall into either the screening or diagnostic category. The patient and her physician should determine the intent and type of study. For screening services, report these patients with the screening code 77057 for bilateral studies or 77057-52 for a unilateral study.

Coding Diagnostics
Diagnosis codes to consider for screening mammograms are found under screening for malignancies, V76.11 high-risk patients or V76.12 for other than high-risk patients. Additional codes that support the patient as high risk should be included and listed as a secondary code to V76.11.

V10.3 Personal history of malignant neoplasm, breast

V16.3 Family history of malignant neoplasm, breast

V15.89 Other specified personal history presenting hazards to health, other

When performing the radiologist’s professional component of a radiology service, append modifier 26. The radiologist’s report should contain a clinical patient history relevant to the study, the interpretation of the films, as well as a final impression.

Diagnostic mammograms will report two classifications of patients; those that are symptomatic (have some type of physical finding or experiencing pain) and those that are currently asymptomatic, but considered to be at high risk. CPT® code 77055 (for Medicare, refer to G0206) describes a diagnostic mammogram for a unilateral study; while code 77056 (for Medicare, refer to G0204) is used for a bilateral study. Since the codes don’t specify the number of views, use one code along with one billing unit to report your services regardless of the number of views taken.

Men are also susceptible to breast diseases–including cancer. Male patients who exhibit symptoms and present for mammography are considered diagnostic. Refer to the same set of diagnostic codes (77055, 77056, G0204 and G0206) as you would for female patients.

Diagnosis codes for medical necessity depend upon the patient’s presenting complaint. Patients who report breast pain, lumps, nipple discharge, or other symptoms require diagnostic testing. Patients who have a personal history of breast cancer or biopsy confirmed non-malignant breast disease may also fall into the category of diagnostic. For coding purposes, use the diagnosis as listed by the radiologist in his or her final impression. In the absence of a radiologic finding, revert back to the reason (diagnosis or complaint) listed on the original order.

When Additional Diagnostics Are Necessary
When our patients receive a screening mammogram, unfortunately a suspicious area may be identified by the radiologist. During the same encounter the radiologist may order additional diagnostic views. These are sometimes referred to as “magnification and spot compression.” Under these circumstances, Medicare directs us to bill both the screening mammogram and the appropriate diagnostic mammogram. To indicate that a screening mammogram has taken place and ended in the decision for a diagnostic service, attach modifier “GG” to the appropriate diagnostic code. To report medical necessity appropriately, be sure to link a screening ICD-9 code to the screening mammogram CPT® code (77057 or G0202), and the diagnosis code for the abnormal finding to the diagnostic mammogram (77055, 77056, G0204 or G0206).

Many facilities now have the capability of using computer aided detection (CAD) for both screening and diagnostic mammograms. This sophisticated and sensitive piece of equipment assists the radiologist in locating abnormalities on mammography films. CAD is reported as an add-on code to the primary procedure. Use +77051 in conjunction with diagnostic mammograms and +77052 with screening mammograms.

When requesting additional reimbursement for the professional component of CAD, there should be a physician interpretation that addresses any additional findings (or lack thereof) located by the computer. The professional component should be identified through the use of modifier 26 on the radiologist’s claim.

Even though mammography coding seems straightforward, there are many different patient scenarios and payer specific issues to consider when coding this highly specialized area of radiology. Explore different resources for coding and technology advancements to stay up to date with breast imaging; and don’t forget to share the wealth of information you gather with your staff.

Carolyn Posted Tue 21st of May, 2013 19:45:54 PM

your response is blank.

Carolyn Posted Wed 22nd of May, 2013 15:54:10 PM

Yes but what is adequate documentation to support reporting the code?

SuperCoder Answered Wed 22nd of May, 2013 22:26:08 PM

Procedure: Screening Mammography Bilateral

Indication: Routine screening, family history of breast cancer--sister

Findings: Bilateral craniocaudal and mediolateral oblique views were obtained. Computer-aided diagnosis by R2 software system. Since the prior study, the breast parenchymal pattern with mild asymmetry and nodulation appears stable. Axillary lymph nodes are present.

Recommendation: Yearly surveillance is suggested.

Birads Category: 2--Benign

Step 1. Choose Your ICD-9 Codes

From the documentation, you know that the patient received a routine screening mammogram and has a sister with a history of breast cancer. Both of these facts are important to choosing your diagnosis codes.

When the patient has a screening mammogram, you need to choose between high-risk screening code V76.11 (Screening mammogram for high-risk patient) and screening code V76.12 (Other screening mammogram).

CMS considers the following patients to be high-risk, Buck says (see www.cms.hhs.gov/Transmittals/Downloads/R426CP.pdf for the exact CMS language):

• personal history of breast cancer (V10.3, Personal history of malignant neoplasm; breast)

• family history of breast cancer (V16.3, Family history of malignant neoplasm; breast)

• Mother
• Sister
• Daughter
• no childbirth prior to age 30 (V15.89, Other specified personal history presenting hazards to health; other)
• personal history of biopsy-proven benign breast disease (V15.89).

The example patient has a sister with a breast cancer history, which CMS lists as a high-risk factor, so you should consider the example mammogram a high-risk screening mammogram.

What to do: Report V76.11 first, and then report V16.3 to explain the reason for choosing the high-risk screening code.

Step 2: Be Careful With CPT Codes

Your documentation indicates that the patient received a screening mammogram, pointing to 77057 (Screening mammography, bilateral [2-view film study of each breast]) as the appropriate code.

Providers order these mammograms for asymptomatic females who haven’t manifested any clinical signs, symptoms, or physical findings of breast cancer, Buck points out.

Screening mammography must be at least a two-view exposure of each breast:

1. cranio-caudal (CC)

2. medial lateral oblique (MLO).

See Medicare National Coverage Determinations Manual Chapter 1, Part 4, Section 220.4 (Mammograms) for the exact CMS language, www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf.

Your documentation indicates the required views and includes an interpretation of them, so 77057 is the appropriate code.

Don’t miss: Add-on code +77052 (Computer-aided detection [computer algorithm analysis of digital image data for lesion detection] with further physician review for interpretation with or without digitization of film radiographic images; screening mammography [list separately in addition to code for primary procedure]) describes an added computer-aided detection service providers may use for screening mammograms.

For you to report this code, the radiology report must document computer-aided diagnosis use for the exam, says Barbara Rutigliano, MS, RT(R), CPC, RCC, coding manager with Jefferson Radiology in East Hartford, Conn.

The sample report documentation indicates “computer-aided diagnosis by R2 software system.”

What to do: Report 77057 and 77052 for the documented procedures.

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