All About Screening and Diagnostic Mammograms

Categories:   Diagnosis Coding   Diagnostic Testing   Preventive Medicine Service   Screening  

When billing for mammograms, documentation must include the purpose and the result of the procedure. Two major purposes of mammogram are diagnostic and screening. It can also be used mammography to guide other procedures.

Determine the purpose of the procedure; i.e. whether it was performed for diagnosis or screening. 

Diagnostic: There are two codes for diagnostic mammography. Bill CPT® codes 77055 and 77056 depending on whether the procedure was perform on one or both sides.

 

Screening: Screening Mammography is done on asymptomatic woman for early detection of breast cancer. You should CPT® code 77057 for screening mammography. 

 

To perform screening mammography, there need not be signs, symptoms, or any history of breast disease. The screening exam will be covered even without a prescription or referral from another doctor. Medicare specifies age and frequency for patients for whom screening mammography is covered. However, when the radiologist performs a diagnostic mammogram; there should be a physician’s order, some signs and symptoms, or a personal history for which the test is warranted.

Note: You should not use number of views as a criterion to distinguish screening vs. diagnostic. Screening mammography usually is has two views craniocaudal (CC) and mediolateral oblique (MLO). However, the number of views should not be considered a criteria to differentiate a screening mammogram from a diagnostic one because more than two views may be required for screening mammogram in certain situations. Typically  diagnostic mammogram has latero-medial (LM) or medio-lateral (ML) views along with the CC and MLO views.

If both screening as well as diagnostic mammograms are performed on the same day, report both and append modifier GG to the diagnostic mammogram code. If the patient visits the radiologist for a routine screening mammogram, and an abnormality is identified, they might perform unilateral or bilateral diagnostic mammogram. In such cases, Medicare will cover both the exams. 

 

Age is an important criterion:  Medicare will pay for screening mammograms under certain condition.

 

·         Screening mammography is not covered for patients under age of 35 years.

 

Screening mammography is typically performed on both breasts and therefore, the description includes “2-view film study of each breast”. In case a screening exam is done on a patient who had a mastectomy, screening is done unilaterally. In such case, use code 77055 (Mammography; unilateral), because, the criterion for personal history is satisfied. Also, ICD-9-CM codes V10.3 (Personal history of malignant neoplasm of breast)should be reported to justify. You can check with the payer in case they have any other specific rule for such scenarios.

Changes to the Medical Decision Making (MDM) Table in 2023 reflect the work performed in the facility setting in addition to the work involved in Evaluation and Management (E/M) scoring in other places of service. Taking the time to really look closely at the MDM Table and identify patterns in wording and scoring helps coders to understand scoring in an easier way.

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Hospitals are increasingly adopting innovative solutions to improve patient care and optimize processes and many of these solutions follow immediately the recent CPT and Medicare coding changes.  In 2023 coding of hospital observation care services underwent significant changes enabling healthcare providers to accurately document and bill for the sick or injured patient that requires a higher level of medical services between the emergency room care and hospital admission. This article explores the key changes in coding hospital observation care services and their impact on healthcare delivery.

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The Office of the Inspector General (OIG) recently published their Spring 2023 Semiannual Report to Congress. This report contained some diagnoses reporting issues that all providers need to be aware of. They focused on several groups of diagnoses that they considered “High-Risk” for being miscoded. Several states were included in the report and the types of errors for all can be generally grouped into several categories.

Historically, the 10-day and 90-day global periods would include the patient's follow-up Evaluation and Management (E/M) services and any dressing changes or staple/suture removal related to the surgery; however, following a closer analysis of these and other surgery codes, the decision was made to make significant revisions to these codes to ensure proper reporting.

It’s probably not surprising that the most commonly billed imaging services are radiologic examinations of the humerus, spine, fingers, and abdomen (codes 72070, 73140, 73060, 74019). However, there are currently 653 CPT codes in the main imaging section (70000-79999). Therefore, it’s worth it to take a few moments to review some important information about these services to ensure that proper coding (including the correct use of modifiers) takes place. This can help your organization ensure correct coding and reimbursement and thus minimize the chances for claim denials and payer take-backs (post-payment denials).