How to Code for Screening Mammogram When Radiologist Finds Problem?

Watch out: Results don’t turn screening into diagnostic

Question: A patient presented for a screening mammogram, and the radiologist determined the patient needed an ultrasound for a closer look. The patient returned for that test at a later date. Should I code the original mammogram as 77056 instead of 77057 because the radiologist found a possible problem?

Answer: If the patient presents for and undergoes a screening mammogram, you should code for a screening, even if the radiologist discovers an abnormality. In the case you describe you would report 77057 (Screening mammography, bilateral [2-view film study of each breast]) rather than 77056 (Mammography; bilateral). When the patient returns for the ultrasound, you would report 76645 (Ultrasound, breast[s] [unilateral or bilateral], real time with image documentation). Remember that Medicare requires a separate order for the ultrasound for nonhospital patients.

For the 77057 service, you also should report the appropriate V code (V76.11, Screening mammogram for high-risk patient; or V76.12, Other screening mammogram) and the appropriate ICD-9 code to describe the abnormality the radiologist noted. ICD-9 official guidelines state that the “V code indicates that a screening exam is planned. A procedure code is required to confirm that the screening was performed.”

Helpful: Part of Medicare’s screening mammogram definition states it is “a radiologic procedure provided to an asymptomatic woman for the purpose of early detection of breast cancer” (emphasis added). The patient does not need an order or referral for Medicare to cover a screening mammogram, as long as she meets age and frequency requirements (Medicare Benefit Policy Manual, Chapter 15, Section 280.3).

A diagnostic mammogram, on the other hand, requires an order from the treating physician based on symptoms, history, or some other factor that the treating physician believes makes a diagnostic mammogram necessary. For a diagnostic exam, you would choose your ICD-9 code based on the radiologist’s findings or, if the exam is normal, based on the reasons for the diagnostic exam.

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