August 31, 2007

ACR Radiology Coding Source™ July-Aug 2007

Q: How should the use of computer-aided detection software be reported for breast sonography services? 

A: Computer-aided detection (CAD) performed in conjunction with breast sonography is reported with Current Procedural Terminology (CPT) code 76999 (unlisted ultrasound procedure (e.g., diagnostic, interventional) to describe the CAD analysis and CPT code 76645 (ultrasound, breast(s) (unilateral or bilateral), real time with image documentation) to describe the breast ultrasound study. Although CAD codes have been established to be used in conjunction with diagnostic and screening mammography (77051, 77052) and breast magnetic resonance imaging (MRI) (0159T), no code is available to be used in conjunction with breast ultrasound; therefore, the unlisted procedure code should be used to report this service. 

Q: Is an order required for the use of CAD? Must the use of CAD be dictated in the report? 

A: The add-on procedure code for CAD is exempt from the Ordering Diagnostic Tests rule and, therefore, does not require a separate order from the referring physician. 

The Centers for Medicare and Medicaid Services (CMS) informed the ACR that the Ordering of Diagnostic Tests rule (42 CFR 410.32) allows for performance of computer-aided detection in conjunction with mammography without a written order from the referring (treating) physician. Since there is no medical necessity prerequisite for the use of CAD with mammography procedures, and if all aspects of CAD are performed in conjunction with mammography, the radiologist may determine whether or not CAD should be performed. The use of CAD in conjunction with mammography is covered under the Radiologist Exception as noted in Medicare Transmittal #1725: 

15021 (E)(1) Test Design - Unless specified in the order, the radiologist may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or nonuse of contrast media). 

When CAD is used in addition to a mammography procedure, it should be documented in the report. 

Q: In a freestanding office or independent diagnostic testing facility (IDTF) setting, is a separate order required for the breast ultrasound study recommended by the radiologist to further evaluate a suspicious finding on screening mammography? 

A: Yes, a separate order is required in the freestanding office and IDTF settings for the addition of a breast ultrasound study following a screening mammography procedure to further evaluate a suspicious finding. The rationale that allows for the performance of a diagnostic mammogram following a screening mammogram without an order from the referring physician does not apply to additional diagnostic testing such as ultrasound or MRI. The National Office of the Centers for Medicare and Medicaid Services (formerly known as the Healthcare Financing Administration [HCFA]) notified the ACR that Medicare proposed and adopted the diagnostic mammography exception to the Ordering of Diagnostic Tests rule because Congress made the Food and Drug Administration, rather than HCFA, responsible for the conditions under which mammograms are covered. In addition, the screening mammography benefit contains no requirement for a physician’s order. Thus, a beneficiary could receive the screening mammogram on a walk-in basis, with no treating physician to order the subsequent diagnostic procedure. 

If a diagnostic breast ultrasound study is required after a screening mammogram, the radiologist must obtain a separate order from the referring physician in the freestanding office and IDTF settings.