To help simplify coding and billing for screening and diagnostic mammograms, this article will provide guidelines and definitions from both Medicare and the American College of Radiology (ACR).

Per the Center for Medicare and Medicaid Services (CMS) NCD 220.4, the definition of a screening mammogram is:

“…a radiologic procedure furnished to a woman without signs and symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician’s interpretation of the results of the procedure.”

A standard two-view minimum (craniocaudal and mediolateral oblique) are required of each breast. Medicare will not pay for a screening mammogram on a woman under the age of 35 and only once for a woman over age 34 but under age 40. For patients over the age of 39, Medicare will pay for a screening for an asymptomatic woman once a year.

When supplemental views are performed to better visualize breast tissue, this is included in the base exam and not separately reported. This procedure is often done on a patient with augmented breast. If a screening exam is performed and after review of the images, additional views are obtained on the same day due to suspect pathology, Medicare guidelines state that a screening and diagnostic exam may be reported. The diagnostic study should be reported with modifier GG.

Per the CMS NCD 220.4, the definition of a diagnostic mammogram is:

“…a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven breast disease, and includes a physician’s interpretation and results of the procedure.”

A referral for a diagnostic mammogram should provide sufficient information regarding the medical necessity of the exam.

Per the ACR Practice Guidelines (PDF, 236 KB), a diagnostic mammogram may be appropriate for patients:

  1. With a specific focus of clinical concern; i.e. mass, nipple discharge, pain, etc.
  2. With possible radiographic abnormality detected on prior screening mammogram
  3. Recommended for short term follow-up for probable benign radiographic concerns as defined by BI-RADS
  4. Whose examination requires direct involvement of the radiologist for special views, breast physical exam or consultation
  5. Who have been treated for breast cancer; at the discretion of the facility, asymptomatic women may undergo a screening or diagnostic mammogram

Most of the time, the referral from the treating physician will determine whether a patient is to have a screening or diagnostic exam, although an asymptomatic patient may receive a screening mammogram without a referral. In cases where a patient has breast augmentation as the reason for exam, per the ACR, it is up to the facility and or the interpreting physician to determine whether to do a screening or diagnostic exam. However, CMS payment policy (according to American Medical Association (AMA) Clinical Examples in Radiology volume 1, issue 4, fall 2005) does not recognize breast implants as reason for a diagnostic study and will only pay for a screening in this case. In cases where the patient has had a history of mastectomy, CMS allows the attending physician and the patient the flexibility to choose whether to continue with diagnostic mammograms or revert back to screenings. In cases where the patient does have a history of a mastectomy and a screening mammogram is done unilaterally, it is recommended that the screening mammogram CPT code G0202/77057 be used with a modifier 52. Check with your payer as some do not require modifier 52.

Coding Evaluation and Management codes with Mammography

There is some confusion in regards to whether a radiologist may bill for an Evaluation and Management (E/M) code on the same day as a mammogram. This issue is such a problem that CMS has given several of the Recovery Audit Contractors (RAC) permission to investigate radiologists who charge for these two services on the same day.

The following are recommendations from two separate resources.

  1. According to a Radiology FAQ in AMA’s Clinical Examples in Radiology, Volume 2, issue 2, spring 2006, “…it would not be appropriate to report an E/M visit following a diagnostic mammogram when done to discuss the findings and recommendations with the patient.”
  2. According the ACR Radiology Coding Source, May/June 2006 :
    Q: If a physical exam is performed in conjunction with a diagnostic mammogram or breast ultrasound and the results are discussed with the patient, is it appropriate to bill for an office visit, 99212, if performed in a private office setting?
    A: It is only appropriate to bill for a consultation or other evaluation and management (E/M) service when the service is provided and documented according to established E/M guidelines. For breast interventional procedures, a brief review of history and physical exam and obtaining informed consent is not a separately reportable E/M service. This service is considered bundled into the surgical procedure code.”

The RAC investigation was centered on Regions A and B which is DCS Healthcare. The issue is defined as “Identification of overpayment associated with radiologists billing E/M services on the same date of service as a diagnostic mammogram.” According to a local coverage determination (LCD) for this region (LCD 26890):

“components of a diagnostic mammogram include a brief history, palpitation of the breasts (when indicated), the mammogram, interpretation and report, and communication of the results to the patient.... Diagnostic mammography may require that the performing radiologist review the history with the patient, review prior mammograms, and perform an examination as part of the mammography and typically discuss the findings with the patient.”

In the section of the LCD on limitations of coverage it states:

“E/M services should not be coded in addition to the mammogram on the same date or on a subsequent date, by a provider whose sole responsibility is the performance of the mammogram (i.e. radiologist).”

Although this RAC issue is driven by a specific LCD, remember that, as noted in both articles mentioned above from the ACR and AMA, E/M services may only be billed when the service is provided and documented according to the established E/M guidelines. According to Medicare’s Claims Processing Manual (PDF, 1 MB), chapter 12, 30.6.10, the criteria for consultation services are:

  • Specifically, a consultation service is distinguished from other evaluation and management service because it is provided by a physician whose opinion or advice regarding a specific problem is requested by another physician or appropriate source.
  • A request for a consultation from an appropriate source and the need for consultation (i.e. the reason for the consultation) shall be documented by the consultant in the patient’s medical record…
  • After the consultation is provided, the consultant shall prepare a written report of the findings and recommendations, which shall be provided to the referring physician.

In other words, a consultation/evaluation and management service cannot be reported unless at the request of a referring physician with documentation for the need for the consultation in the patient’s medical record and a written report shall be furnished to the requesting physician. If the patient comes in for a diagnostic mammogram only and radiologist does a physical exam and discusses the results of the exam and mammographic findings with the patient, this does not constitute billing for an E/M service.

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About the author

Sandra Stevens, CPC, CIRCC is Compliance - Radiology of McKesson Business Performance Services.