June 30, 2013

ACR Radiology Coding Source™ for May-June 2013 Q and A

Q: Would you please provide coding guidance for the performance of screening and diagnostic breast tomosynthesis studies using the Hologic C-View for reconstruction of a two-dimensional tomosynthesis dataset?

A: The Hologic C-view is new technology that can be used for screening or for diagnostic mammography.
 
When a screening breast tomosynthesis study is performed using the Hologic C-view for reconstruction of a two-dimensional tomosynthesis dataset, it is appropriate to report the unlisted diagnostic procedure code 76499 to describe the breast tomosynthesis study and HCPCS Level II “G” code G0202, Screening Mammography, producing direct digital image, bilateral, all views to describe the reconstruction of the two-dimensional tomosynthesis dataset.
 
When a diagnostic breast tomosynthesis study is performed using the Hologic C-view for reconstruction of a two-dimensional image set, it is appropriate to report the unlisted diagnostic procedure code 76499 to describe the breast tomosynthesis study and HCPCS Level II “G” code G0204, Diagnostic Mammography, producing direct digital image, bilateral, all views or G0206, unilateral, to describe the reconstruction of the two-dimensional image set.
 
Computer-aided detection (CAD) can only be applied to full images, not spot films or magnification views. CAD is not yet available for synthetic planar images or for tomosynthesis. 
 

Q: What is the appropriate diagnostic imaging exam for a male >30 y.o. presenting with a clinical abnormality? Our practice routinely performs a bilateral diagnostic exam including bilateral CC, MLO, and unilateral ML or LM for the affected breast. This has been called into question by our coding staff. Similarly, how should an exam for a unilateral diagnostic indication (e.g., breast lump) be coded? Historically, we have coded as a bilateral diagnostic exam, but have recently been asked to change to a unilateral screening for the unaffected breast and unilateral diagnostic for the affected breast coding scheme.

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:

  1. 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
  2. With a possible radiographic abnormality detected on screening mammography 
  3. 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®) 
  4. Whose examination requires direct involvement of the radiologist for special views, breast physical examination, or consultation 
  5. 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.

Q: Are code(s) available to report a nuclear medicine myocardial sympathetic innervation imaging study?

A: Two Category III CPT codes were developed and are available for reporting myocardial sympathetic innervation imaging as of July 1, 2013. Code 00331T, Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment describes a planar study, and code 0332T, Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT, describes a planar and SPECT study. The quantitative assessment of the heart to mediastinum (H/M) ratio is included in codes 0331T and 0332T and is not reported separately. 
 
The radiopharmaceutical I-123 mIBG, used to performed a myocardial sympathetic innervation imaging study, should be reported with the Healthcare Common Procedure Coding System (HCPCS) Level II code A9582 Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries. It is important to report the radiopharmaceutical codes separately even though there may be no reimbursement. The reporting of radiopharmaceuticals is used in the hospital outpa¬tient prospective payment system and by other payers to set future payments for radiopharmaceuticals.