A: When a patient presents with signs and symptoms of breast disease, a diagnostic mammogram of both breasts should be performed and reported. The ACR published a breast imaging FAQ in the July/August 2008 issue of the ACR Radiology Coding Source. As noted in this issue, the Centers for Medicare & Medicaid Services (CMS) National Coverage Determination notes the following definitions for screening and diagnostic mammography:
“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 benign breast disease, and includes a physician's interpretation of the results of the procedure.”
“A screening mammogram is a radiologic procedure furnished to a woman without signs or 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 screening mammogram has limitations as it must be, at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast.”
The ACR Practice Guidelines, Section IV, Patient Selection, notes the following.
Diagnostic mammography may be appropriate for patients:
- With a specific focus of clinical concern including, but not limited to, mass, induration, axillary lymphadenopathy, some types of nipple discharge, skin changes or persistent focal areas of pain or tenderness
- With a possible radiographic abnormality detected on screening mammography
- Recommended for short-interval follow-up (e.g., less than one year) for probably benign radiographic concerns as defined by the ACR Breast Imaging Reporting and Data System (BI-RADS®)
- Whose examination requires direct involvement of the radiologist for special views, breast physical examination, or consultation
- Who have been treated for breast cancer. At the discretion of the facility, asymptomatic women may undergo screening or diagnostic mammography.
Therefore, whenever a diagnostic study is indicated, it is appropriate to do a diagnostic mammogram on one or both breasts as indicated. It is not appropriate to do a screen of one breast and a diagnostic of the other. In the specific case of a 30-year-old male who presents with a clinical abnormality of the breast, a diagnostic study should be performed. If a patient presents for their annual screen and a breast lump is felt, that is an indication for a bilateral diagnostic study. For biopsy-proven benign breast disease, a diagnostic or screening study may be performed. 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 a diagnostic mammogram is performed.