June 30, 2006

ACR Radiology Coding Source™ May-June 2006 Q and A

Q: Please clarify whether a screening mammogram or a diagnostic mammogram should be performed on an asymptomatic patient with augmented breasts (eg, breast implants).

A: According to the ACR's Standard for Diagnostic Mammography, a diagnostic mammogram should be performed on patients with augmented breasts. However, the Centers for Medicare and Medicaid Service's (CMS, formerly known as HCFA) payment policy for a diagnostic mammogram does not recognize asymptomatic patients with augmented breasts as diagnostic. Medicare will only pay for a screening mammogram for an asymptomatic woman with breast implants.

Since Medicare denies the necessity of a diagnostic mammogram for an asymptomatic patient with augmented breasts, an advance beneficiary notice (ABN) should be obtained from the patient if the radiologist plans to bill the patient for a diagnostic mammogram. If the patient and referring physician decide that a screening mammogram should be performed, then the patient would receive a screening mammogram.

Q: What type of mammogram should a patient receive who has a personal history of biopsy-proven benign breast disease?

A: According to the ACR Standard for Diagnostic Mammography, a diagnostic mammogram is appropriate for patients with a personal history of biopsy-proven benign breast disease. Also, as noted in the Dec. 8, 1995 Federal Register, CMS expanded its definition of diagnostic mammography to include a personal history of biopsy-proven benign breast disease, thereby allowing the attending physician and the patient the opportunity to determine whether a screening mammogram or diagnostic mammogram is performed.

Q: Is there a guideline that states that patients with a history of mastectomy must revert to a screening mammography study after a set number of negative diagnostic studies or after a specified number of years postmastectomy?

A: The ACR considers patients who have been treated for breast cancer (either with breast conservation or mastectomy) high-risk patients, an indication for a diagnostic mammogram for the rest of their lives. However, as stated above, CMS allows the attending physician and the patient the flexibility to choose whether they want to continue with a diagnostic mammogram or revert back to the screening process.

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.

Click here for a copy of the documentation guidelines. The E/M guidelines are currently under review. Until the E/M documentation guidelines are finalized, it is up to the provider to use either the 1995 or 1997 published guidelines. It is recommended, however, that for auditing purposes a radiology practice use one set of guidelines, ie, either 1995 or 1997.

Q: Is a consent form by the patient required for breast cyst aspiration or core biopsy?

A: Yes. The requirements for an informed consent for breast cyst aspiration or core biopsy are no different than obtaining consent for any other invasive or interventional procedure.