coding corner
How to Code Mammographies
Jeff Majchrzak, BA, (RT)NMTCB
On January 23, a 
middle-aged woman received a call from her radiologist asking her to come to the office the next day to discuss her bilateral screening mammogram results. That evening, she went to dinner with her family. About three hours later, she became nauseous and began cramping and vomiting.
At first she attributed this to indigestion or food poisoning, but the symptoms persisted into the next day. She decided not to go to the emergency room but to wait until she met with the radiologist. If the symptoms were still present then, she would discuss them.
Screening, Diagnostic
And Invasive Studies
The patient returned to the radiologist’s office to discuss the mammogram results. She was so concerned about this that, even though she still felt ill, she did not want to mention it to the radiologist. The radiologist recommended additional imaging of the right breast to clarify a suspected, nonpalpable abnormal area with possible stereotactic biopsy to follow. The radiologist noted in the record, “Patient returned for follow-up on mammogram results.”
Images taken in multiple projections showed an abnormality. The patient was positioned in the stereotactic unit for biopsy and potential marking to assist the surgeon if a surgical biopsy was needed. The stereotactic biopsy was done with nine specimens acquired. A titanium clip was left in place to define the area for surgical biopsy.
The patient went to the surgical suite where a specimen was obtained and sent to pathology for evaluation. Another sample was sent to radiology for radiographic examination. The patient returned home to await the results. Her nausea persisted, but she did not seek treatment.
Hospital and Physician Billing
Based upon the procedures performed, you would submit the CPT codes listed below. Hospitals should assign the revenue codes (RCs) that follow in parenthesis. Also, assign modifiers as instructed by national and local current Part B Medicare reporting requirements.
* 76092-26 (RC 403) for the bilateral screening mammogram
* 76090-26 (RC 401) for the unilateral diagnostic mammogram performed the next day
* 76095-26 (RC 32x) for the stereotactic localization procedure
* 76098-26 (RC 32x) for the surgical specimen radiography
* 19101 (RC 36x or 490) for the procedural aspect of the stereotactic biopsy
* 19290 (RC 36x or 490) for the placement of the marker (clip) during the stereotactic procedure
The follow-up visit after the mammography is not coded as an evaluation and management (E&M) service because the physician did not document the services performed during the visit in enough detail. However, the appropriate level of E&M CPT code could be assigned if the following conditions had been met and the payer policy does not consider such coding as unbundling.
The physician would have had to:
* document that counseling and coordination of care constituted more than 50 percent of the visit;
* include a detailed description in the medical record that he or she discussed the study findings, possible diagnoses and treatment options with the patient; and
* document the amount of time spent performing these services as well as coordination of care with the surgeon if a surgical biopsy was necessary.
The woman’s nausea was not treated and is not coded.
Hospital Billing
Unless radiologists perform these procedures in entities they own, charges for the drugs, contrast, supplies, etc. should not be submitted. Hospitals, however, may charge for these items.
Hospital supplies used in conjunction with these studies may be either included with the exam charge or broken out separately. If listing separately, report with RC 621 (supplies incident to radiology and subject to the payment limitation). RCs 255 and 621 do not require CPT or HCPCS codes. (See addendum H of the Medicare Hospital Manual, Publication 10, for the complete listing of services pertaining to RC 621.)
In 1998, no additional, specific Level II HCPCS code existed for the costly stereotactic needle(s) used to perform this exam. As no contrast material was used, no charges can be assigned.
Coding Rationale
Code 76092 defines the bilateral screening study. CPT states that two views of each breast must be done. If the patient had only one breast and screening views were done, use code 76092 and assign modifier 52.
It is correct to assign code 76090 for unilateral diagnostic imaging performed on the next date of service. If the subsequent unilateral diagnostic films were acquired on the same date of service, only 76090 would be used, but the modifier -GH (diagnostic mammogram converted from screening mammogram on same day) also would be assigned to this code. Do not assign code 76092. (For more information, see Medicare Hospital Manual, Transmittal No. 730, Subsection F, Special Billing Instructions When a Radiologist Interpretation Results in Additional Films, July 1998.)
Code 76095 defines the radiological supervision and interpretation (S & I) portion of the stereotactic biopsy. Regardless of the number of passes made through the same lesion, report this code only once. If multiple, separate lesions are studied, report the code for each lesion studied. Likewise, the surgical code for the procedural aspect of the stereotactic biopsy (19101) also is reported once per lesion.
A titanium clip (marker) also was placed at this setting for marking purposes during stereotactic breast biopsy. Although the Health Care Financing Administration has not issued any directives about using code 19290, the Blue Cross Blue Shield of North Dakota, a Medicare contractor, recently issued a local medical review policy (Medicare Bulletin #170, December 1998). The bulletin indicates that it is inappropriate to bill for this portion of the procedure, and payment will be disallowed.
However, the American College of Radiology (ACR) did issue a directive regarding appropriate billing of this code (ACR Bulletin, October 1997, (53)10, p. 5). The ACR stated the following: “If a titanium clip is placed at the conclusion of the biopsy to mark the area in cases in which follow-up surgery or localized radiation may be necessary, then 19290 (preoperative placement of needle localization wire, breast) is added.”
Be certain to closely monitor all Part A and Part B data as well as processed claims for these studies to ascertain payer requirements.
Do not report code 76096 in the above scenario as this would result in incorrect payment. Code 76098 defines specimen radiography of any type. This charge should be submitted each time a separate, distinct specimen is sent to radiology with subsequent filming of the sample. *
Jeff Majchrzak is a senior health care consultant at Medical Learning Inc., St. Paul, MN. He is board certified in nuclear medicine technology and radiologic technology and has 13 years of experience in radiology, nuclear medicine and administration.
