Sunday, January 3, 2016

Breast Care and Screening – 2015: Coding & Documentation Strategies

Breast Care and Screening – 2015:  Coding & Documentation  Strategies

October is Breast Cancer awareness month.  In this month, physicians and healthcare professionals have heightened the awareness of patients' to be screened for all types of breast care conditions and breast cancers. 

Breast cancer afflicts both men and women.  ICD-10cm diagnosis codes now recognize and give us the specificity for location, but also designation between men and women.  All of the breast cancer neoplasm codes can be found in ICD-10 under the C-50 codeset.   But what about screening?  ICD10cm has screening codes for usage with mammogram too.

Z12.31 Encounter for screening mammogram for malignant neoplasm of breast, and
Z12.39 Encounter for other screening for malignant neoplasm of breast.

The Mammogram procedure has been performed for a number of years, and CMS has had strict policies on how it is to be paid.  Not only does CPT have Mammography codes, but HCPCS also has 3 codes to be utilized for mammography also.  In 2015 CPT gave us codes for digital breast tomosynthesis which provides higher diagnostic accuracy compared ton conventional mammography.  The usage of Screening breast tomosynthesis offers better detection of abnormalities with a minor increase in the radiation exposure to the breast tissue.  The breast tomosynthesis is routinely used for high resolution, limited angle in the clinical application of breast imaging.   It is somewhat similar in the view as a CT type of scan (computerized tomography)

With the inclusion of the new CPT Tomosynthesis codes, these ne CPT codes must be billed in conjunction with the screening mammography HCPCS codes for Medicare.  This includes all 2D imaging and 3D imaging.  Medicare is also particular that a "screening" diagnosis code be used on these claims and not a diagnostic/problem focused diagnosis.  

Prior to October 1st we were instructed to use only the ICD-9 codes. However, since ICD-10cm is now the valid code-set we need to be using ICD-10cm code Z12.31 or Z12.39 with the appropriate procedure codes.

2015 CPT Codes:

·         77055 Breast Mammography – Diagnostic Unilateral
·         77056 Breast Mammography – Diagnostic Bilateral
·         77057 Breast Mammography Screening Bilateral 
·         77061 Digital Breast Tomosynthesis; unilateral
·         77062 Digital Breast Tomosynthesis; bilateral
·         +77063 Screening digital Breast Tomosynthesis   (add-on code)

·         77058 Breast MRI Imaging Mammography
·         77059 Breast MRI Imaging Bilateral Mammography
·         76641 Breast Ultrasound Unilateral real time with image documentation complete
·         76642 Breast Ultrasound limited

2015 HPCPS Codes
·         G0202 Screening mammography, producing direct digital image, bilateral, all views
·         G0204 Diagnostic mammography, producing direct 2-d digital image, bilateral, all views
·         G0206 Diagnostic mammography, producing direct 2-d digital image, unilateral, all views

As of August 2012, Medicare will now cover screening mammography depending on the age of the female patient, however, Medicare does not cover screening mammography for men. 

Women younger than age 35
No Medicare payment allowed for Screening Mammography

Women Aged 35 – 39 years
Baseline Mammogram – Medicare will only pay for one screening for women in this age group

Women Aged 40 and older
Annual Mammogram (or at least 11 months after the last covered screening mammography)

If the patient is determined to need a Medically necessary/diagnostic  mammogram, those will be covered as often as deemed medically necessary.  Medicare has also put forth an update to the guidelines in helping to distinguish when diagnostic mammography is a covered test.  This information was published in June, 2015  in the Medicare claims processing manual.   This information is noted as below:

Diagnostic Mammography
A diagnostic mammography is a radiological mammogram and is a covered diagnostic test under the following conditions:

• A patient has distinct signs and symptoms for which a mammogram is indicated;

• A patient has a history of breast cancer; or

• A patient is asymptomatic, but based on the patient’s history and other factors the physician considers significant, the physician’s judgment is that a mammogram is appropriate.

Medicare also requires us to add the new modifier "GG".  This modifier allows the patient to have a screening mammogram and a diagnostic mammogram on the same day.  If the patient is having a  screening mammogram performed, but the radiologist determines a need for a diagnostic mammogram on the same day, Medicare will pay for both services if we add the modifier GG.

In regard to commercial payers, the new digital breast tomosynthesis codes may be considered "experimental" or "investigational" and not be covered for breast cancer screening.   As a coder, an inquiry to the carrier should be part of your process if unsure if a specific 3rd party payer may not pay for this service.  

Tips & Strategies for diagnosis coding in ICD-10cm

Now that we are fully engaged in coding for ICD-10cm, we are instructed to use the screening code of Z12.31 (encounter for screening mammogram for malignant neoplasm of breast).  In addition iif the patient also has a family history of breast cancer, the Z80.3 family history diagnosis should also be appended to your claim. 

When we are coding for a diagnostic mammogram, the screening code of Z12.31 or Z12.39 should never be used in our claims.  The signs and symptoms reported in the notes would normally be coded as a priority.  However, the claim can be held until the mammography interpretation has been completed by the radiologist, and the coding should be representative of what was noted within the radiologist notes.    If the exam is "normal" or "inconclusive"  then the coder should still code based upon any signs and/or symptoms noted. (eg. Breast pain).  If the radiologist notes a definitive diagnosis such as breast calcifications, then the codes from the R92 code-set should be used.

R92 Abnormal and inconclusive findings on diagnostic imaging of breast
·         R92.0 Mammographic microcalcification found on diagnostic imaging of breast
·         R92.1 Mammographic calcification found on diagnostic imaging of breast
·         R92.2 Inconclusive mammogram
·         R92.8 Other abnormal and inconclusive findings on diagnostic imaging of breast

Coding of a breast neoplasm based upon mammography should only be done if the patient has a neoplasm that is documented by the radiologist in the radiology interpretation.  Coders should not make an "assumptive" leap to code from the C50 code-set, unless specifically noted by the radiologist.

Coding of mammography for female patients that have breast implants also can be confusing.   If a patient is having a screening mammogram and also has breast implants, then the Z12.31 will be coded as the primary code, and the code Z98.82 which denotes that the patient currently has breast implants.  If the patient is currently having a mammogram due to a problem with their implants, then a complication code, or symptom code would be the diagnosis driver for a diagnostic mammogram, and not a screening mammogram.  If the patient had breast implants previously, and has had them removed, the Z98.82 implant status code is no longer valid.  ICD-10cm gives us code Z98.86 which informs that the patient has a personal history of breast implant removal.

Breast MRI and Breast Ultrasound

Breast MRI and breast ultrasound codes are not normally used for screening type of services.  These methods of imaging are for diagnostic review and for determining a more definitive diagnosis in patients with abnormal mammogram services.

Most Breast MRI services are performed for patients that have dense breasts or are at high risk for breast cancer.  Some breast MRI's are performed with a breast lump, that does not show up on traditional mammogram, but can be felt/palpated by the provider.  The usage of breast MRI has also been done for patients with breast implants, to avoid the possibility of an implant rupture during traditional mammography.

In 2015 CPT did create new codes for breast ultrasound.  The breast ultrasound codes denoted a unilateral "complete" exam and a unilateral "limited" exam.  CPT code 76641 breast ultrasound complete, the clinical documentation needs to include the examination of all four quadrants of the breast and regroareolar region.  If less than the above was performed, then the limited breast ultrasound code 76642 should be reported.  If both breasts have been imaged, as a coder, you have the option to either append the "50" bilateral modifier, or  usage of the "rt" and "lt" modifiers for each breast.  If you are unsure which to append, contact the 3rd party insurance payer and request guidance of how they prefer the claims to be coded.  Medicare covers breast MRI when clinically indicated and medically necessary.  The list below is not an all inclusive list, but ones that Medicare has deemed as a "diagnostic" indicator for usage of breast MRI.
Ø  Pain in breast
Ø  Lump/mass in breast
Ø  Other specified breast disorder
Ø  Unspecified breast disorder
Ø  Symptoms breast discharge-other
Ø  Breast Cancer (NOS)
Ø  Breast neoplasm\uncertain behavior
Ø  Fibrocystic breast disease
Ø  Cystic breast
Ø  Hypertrophy breast
Ø  Inflammation disease of breast
Ø  Mechanical complication of Prosthetic Device/Breast Implant

Clinical Case Study – Clinical Documentation

Case #1
A 39 year old woman with a family history of breast cancer in her sister (who is age 40) has a bilateral mammogram that reveals breast tissue with no suspicious findings.   Patient is at increased risk for breast CA due to her family history.  Radiologist recommends additional screening test of a breast MRI. 

Coding consideration:
CPT: 77057 Screening mammogram   ICD-10:  Z12.31 screening mammogram

Case #2
A 39 year old woman with a family history of breast cancer in her sister (who is age 40) has a bilateral mammogram that reveals very dense breast tissue with suspicious findings on the left breast.   Patient is at increased risk for breast CA due to her family history.  Radiologist recommends additional views lt breast mammogram and a breast MRI on the left breast.  All are performed same day.

Coding consideration
CPT 77057.GG screening mammogram bilateral   ICD-10: Z12.31
CPT 77055.LT diagnostic mammogram   ICD-10: R92.2
CPT 77058.LT breast MRI  ICD-10cm R92.2

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:  

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