Examine Medicare’s coverage guidelines.
Question: My ob-gyn sees a patient who has breast implants or breast augmentation and orders a mammogram. Should I count the mammography as a screening or a diagnostic test?
Louisiana Subscriber
Answer: Implants and augmentation don’t equate to a diagnostic mammogram every time. The ordering physician decides whether the patient requires a diagnostic mammogram.
Diagnostic: To be a diagnostic mammogram (such as 77056, Mammography, bilateral), the ob-gyn must …
… order the diagnostic service for a patient who has one of two requirements, states Medicare Claims Processing Manual, chapter 18, section 20.B (www.cms.hhs.gov/Manuals/IOM/list.asp).
The patient must either have: signs or symptoms supporting medical necessity, or a personal history or other factors the physician decides merit a diagnostic service.
Watch for: If the screening reveals a potential problem, Medicare allows the radiologist or ob-gyn to order or perform additional mammography views on the same date as the screening. When billing for these additional views report the appropriate diagnostic mammogram code and append modifier GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day). If the implants cause poor visibility or other problems, causing additional views to be ordered or performed, some payers may count these as diagnostic views on the same date.
Screening: Unlike a diagnostic mammogram, a screening mammogram is for asymptomatic patients, according to the Medicare Benefit Policy Manual (MBPM), chapter 15, section 280.3. Medicare will cover screening mammograms even without a physician order for women who meet age and frequency requirements. No doubt you’ve heard that the U.S. Preventive Services Task Force (USPSTF) recently recommended that women between the ages of 50 and 74 should have mammogram screenings every two years instead of every year and doesn’t recommend screening for other average-risk women. But Medicare still applies the following coverage guidelines:
- Under age 35: No payment allowed for screening mammography.
- 35-39: Baseline (pay for only one screening mammography performed on a woman between her 35th and 40th birthdays).
- Over age 39: Annual (11 full months have elapsed following the month of last screening). Use the appropriate screening code, such as 77057 (Screening mammography, bilateral [2-view film study of each breast]).
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