Best Practice And Measure Tips
- This measure evaluates preventive screening only. Bilateral or unilateral screening mammograms are acceptable. Biopsies, breast ultrasounds or MRIs are not acceptable.
- Results can be submitted for medical record review throughout year, but medical record review cannot be performed during HEDIS annual audit.
- If documenting a mammogram in a members history specify mammogram and date of service. If unilateral mammogram, must include documentation of unilateral mastectomy. If the date is unknown, year only is acceptable. The result is not required.
- Submit the appropriate ICD-10 diagnosis code that reflects a members history of bilateral mastectomy, Z90.13.
- Attempt to obtain reports for member reported screening. Notate place of service if unable to obtain report.
- Educate members on importance of screening mammogram for early detection of breast cancer when there are usually no symptoms.
- The advanced illness exclusion can be identified from a telephone visit, e-visit or virtual check-in.
What Cpt Code Should Be Used To Report A Core Breast Biopsy Performed Using Both Stereotactic And Tomosynthesis Imaging Guidance
The AMA/ACR Clinical Examples in Radiology Fall 2016 issue provides guidance on the reporting of both a stereotactic and tomosynthesis imaging-guided core breast biopsy as follows:
When a breast biopsy is performed using both stereotactic and tomosynthesis imaging guidance, it is appropriate to use CPT code 19081, Biopsy, breast, with placement of breast localization device , when per¬formed, and imaging of the biopsy specimen, when performed, percutaneous first lesion, including stereotactic guidance.
If a combination stereotactictomosynthesis-guided biopsy is performed using a separate piece of equipment and the patient is moved to another unit for a post-procedure mammogram, it is appropriate to report the post-procedure mammogram separately. If the combination stereotactictomosyn¬thesis-guided biopsy is performed using a standard digital breast tomosynthesis mammography unit on which the post-procedure mammogram is also obtained, it is not appropriate to report the post-procedure mammogram separately.
Can 77067 And 77063 Be Billed Together
Procedure code 77063 must be billed with primary procedure code 77067. Reimbursement may be considered for procedure code 77063 when performed on the same date of service, by any provider, as procedure code 77067. Procedure codes 77063 and 77067 will be limited to one per rolling year, any provider.
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What National Provider Identifier Number Should Be Reported When A Self
The Centers for Medicare & Medicaid Services has instructed providers to use the institutions NPI number for self-referred mammograms for all claims submitted on or after May 23, 2008. Please reference the CMS Change Request 6023 MLN Matters® Article which states:
- Institutional providers submitting claims for self-referred mammography services will duplicate the institutions own NPI in the attending physician NPI field on their claims and
- Suppliers submitting claims for self-referred mammography services will duplicate the suppliers own NPI in the attending/referring physician NPI field on their claims.
Diagnosis Coding For Possible Malignancy
How would you feel if your primary care physician and your general surgeon told youand told your insurance company on a claim formthat you had breast cancer, when you didnt have breast cancer?
You actually had atypical ductal hyperplasia, not breast cancer. Not only have they told you, the claim has gone to your insurance company and the insurance company thinks you have breast cancer. And, it is listed in your electronic medical record on your problem list.
Anyone who works in healthcare knows that removing a diagnosis from a medical record at the physician office, at the hospital, and in the insurance companys records will be difficult.
Think about the repercussions for this patient if she later needs to buy life insurance, disability insurance, or a health insurance in a state that allows charing higher rates based on pre-existing conditions.
How did this happen?
Neither the primary care physician nor the surgeon followed ICD-10 coding rules and coded the abnormal sign/symptom.
Instead, they coded the suspected diagnosis.
The patient had a screening mammography done. The mammogram showed clustered calcifications in one of her breasts and a low suspicion for malignancy. Soon thereafter, she had a biopsy. The result of that biopsy was atypical ductile hyperplasia bordering on ductal carcinoma in situ.
The surgeon also assigned D05.12, carcinoma in situ. Two claims have so far been submitted to this patients insurance company stating that she has carcinoma in situ.
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Our State Passed A Law That Requires Mammography Providers To Directly Inform Their Patients Of Their Breast Density Category The Law Includes An Insurance Mandate Covering Screening Breast Ultrasound For Women With Mammography
The appropriate CPT code to report an ultrasound examination of the breast is 76641 or 76642 .
Whenever a screening examination is performed, the screening ICD-10 code is the first-listed, regardless of the findings or any procedure that may be performed as a result of the findings. Therefore, an ultrasound screening examination of the breast should be reported with ICD-10 code Z12.39 . It is recommended that a secondary diagnosis be reported to communicate to the payer that the study was performed for a high risk patient.
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 If Performed In A Private Office Setting
It is only appropriate to bill for a consultation or other evaluation and management 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. The Relative Update Committee database clearly indicates that such discussion of findings with the patient is part of the valued work .
A copy of the 1995 and 1997 E& M published guidelines are available on the Centers for Medicare and Medicaid Services web site. It is up to the provider to choose which published guidelines to follow. However, it is recommended that for auditing purposes a radiology practice use one set of guidelines, that is, either 1995 or 1997.
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Breast Cancer Screening Tests
Mammogram: An X-ray of the breast
Breast Magnetic Resonance Imaging : Magnets and radio waves are used to take pictures of the breast
Clinical Breast Exam: Examination by a doctor or nurse to assess for lumps
Breast Self-Awareness: Noticing changes with how the breasts look and feel and talking with a health care provider about those changes
Resources:
What Are Insurance Billing Codes For Supplemental Breast Screening Tests After Mammography
- In the U.S.A., medical procedures are billed using both an ICD code and a CPT code.
- These codes can be used to check with an insurance company to learn if a specific test should be covered and what out-of-pocket costs may be.
- Coverage varies by state and specific insurance plan.
Below are the insurance billing codes by breast imaging test.
ICD CODE: For women with dense breasts, an appropriate ICD-10 code is 92.2 . Note: other diagnosis codes may also apply based on medical history.
CPT CODES:
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How Painful Is A Breast Biopsy
You will be awake during your biopsy and should have little discomfort. Many women report little pain and no scarring on the breast. However, certain patients, including those with dense breast tissue or abnormalities near the chest wall or behind the nipple, may be more sensitive during the procedure.
What Is The Cpt Code For Breast Exam
The patient preventive medicine services codes 99381-99397 include an age- and gender-appropriate physical exam. According to CPT Assistant, performing a pelvic and breast exam, as well as obtaining a screening Pap smear, are all part of the comprehensive preventive service and should not be reported separately.
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Encounter For Screening Mammogram For Malignant Neoplasm Of Breast
- 2016201720182019202020212022Billable/Specific CodePOA Exempt
- Z12.31 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
- Short description: Encntr screen mammogram for malignant neoplasm of breast
- The 2022 edition of ICD-10-CM Z12.31 became effective on October 1, 2021.
- This is the American ICD-10-CM version of Z12.31 – other international versions of ICD-10 Z12.31 may differ.
type 1 excludes
- inconclusive mammogram (
- 2016201720182019202020212022Billable/Specific Code
Applicable To
- Inconclusive mammography due to dense breasts
- Inconclusive mammography NEC
- Applicable To annotations, or
When Is Mammography Recommended
Screening mammography is recommended for women age 40 and older every one to two years and younger than 40 years of age when the patient has increased risk factors for breast cancer.
In general, screening mammograms are not recommended for women under 40 years of age, in part because breast tissue tends to be more dense in younger women, making mammograms as a screening tool less effective. As there is such a low risk of developing breast cancer in younger women, experts do not believe that it is justifiable to expose them to low levels of radiation or the cost of mammograms unless they do have *high risk factors.
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Is It Appropriate To Combine The Interpretation Of A Screening And A Diagnostic Study Into One Report Or Must Two Separate Reports Be Issued
Yes, it is appropriate to combine the interpretation of a screening and a diagnostic study into one report. According to the ACR Breast Imaging Reporting and Data System * frequently asked questions :
The facility has the option of issuing either separate reports or one combined report. If two reports are issued, each must contain its own overall final assessment ). In either case, the facility can report the exam on the same piece of paper. If the facility decides to issue a single combined report, the facility needs to be aware of the following:
*BI-RADS® was developed by the ACR to standardize mammographic reporting, improve communication, reduce confusion regarding mammographic findings, aid research, and facilitate outcomes monitoring.
Encounter For Screening For Malignant Neoplasm Site Unspecified
- 2016201720182019202020212022Billable/Specific CodePOA Exempt
Z12.39 Encounter for other screening for malignant neoplasm of breast
Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.
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What Is A Breast Tomosynthesis Study And How Is It Coded
Breast tomosynthesis is a digital tomographic technique performed using multiple low-dose X-ray exposures. The resulting image data is reconstructed using standard computer algorithms to produce a series of sequential, stacked slices through the breast. This type of tomographic imaging enables the physician to view the breast as thin, discrete image slices on a computer workstation. The addition of digital breast tomosynthesis to conventional mammography has been shown to be more sen¬sitive and specific for breast cancer detection.
The Current Procedural Terminology Editorial Panel created three Cat¬egory I codes to describe unilat¬eral diagnostic , bilateral diagnostic , and screening breast tomosynthesis procedures, which became available for use as of January 1, 2015. However, CMS recognized 77063 only for screening DBT as an add-on code, but did not recognize the stand-alone diagnostic DBT codes 77061 and 77062. In place of using 77061 and 77062, CMS created the HCPCS Level II add-on code G0279 to describe diagnostic DBT, whether unilateral or bilateral.
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What Is The Icd 10 Code For Breast Exam
An ICD-10-CM diagnosis code should be linked to the appropriate CPT mammography code reported. The proper diagnosis code to report would be Z12.31, Encounter for screening mammogram for malignant neoplasm of breast.
What is the difference between Z12 31 and Z12 39?
Z12. 31 is reported for screening mammograms while Z12. 39 has been established for reporting screening studies for breast cancer outside the scope of mammograms.
What is the ICD 9 code for screening mammogram?
ICD-9 Code V76.12 -Other screening mammogram- Codify by AAPC.
What does diagnosis R92 8 mean?
2022 ICD-10-CM Diagnosis Code R92. 8: Other abnormal and inconclusive findings on diagnostic imaging of breast.
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More News & Resources
Mammography is the process of using low-energy X-rays to examine the human breast, which is used as a diagnostic and screening tool. The goal of mammography is the early detection of breast cancer, typically through detection of characteristic masses and/or microcalcifications.
The ICD-9-CM codes used for mammograms for so long, like V76.12, will be going away. However, the diagnosis coding guidelines for mammograms have not changed so the coding should be easy in ICD-10-CM.
Screening Mammograms
In ICD-10, a screening code will be assigned as the primary diagnosis for a screening mammogram. However, there wont be two screening codes to choose from. ICD-10-CM does not distinguish between low-risk patients and high-risk patients . All screening mammograms should be reported with ICD-10-CM code Z12.31 . Any relevant clinical history or clinical findings as a secondary diagnosis should be coded. For example, if the patient has a family history of breast cancer, her screening mammogram claim with code Z12.31 followed by code Z80.3 will be coded.
Diagnostic Mammograms
A diagnostic mammogram should not be submitted with the screening code, Z12.31. Instead the following points should be taken into consideration while coding:
Mammographic Finding
Inconclusive Mammogram
Breast Implants
What Code Should Be Reported To Describe A Screening Mammogram When Additional Magnification Views Are Required For A Suspected Abnormality May I Code Both A Diagnostic Mammogram And A Screening Mammogram And Is An Order Required
If a screening mammogram is performed and, after review of the images, pathology is suspected, the interpreting physician is allowed to order additional images. When additional views are obtained, Medicare states that it is appropriate to charge for both a screening mammogram and a diagnostic mammogram whether the studies are performed on the same or different days. If the additional views are done on the same day as the screening mammogram, the diagnostic study should be reported with the GG modifier, which Medicare uses for tracking purposes. This modifier designates the performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day.
In March 2015, CMS responded to an appeal from the ACR regarding a newly implemented National Correct Coding Initiative edit for screening mammography and diagnostic mammography performed on the same patient on the same date of service. CMS elected to retain these NCCI edits. Per CMS, if a provider performs both screening and diagnostic mammography on the same patient on the same date of service, CMS instructions require that a provider report modifier GG with the diagnostic mammography code . However, because modifier GG is not an NCCI-associated modifier and will not bypass the NCCI edit, providers are instructed to additionally append modifier 59 to the screening mammography to bypass the NCCI edits.
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