ACR Radiology Coding Source™ for November-December 2014 Q and A

Q: Is the use of the new breast tomosynthesis codes dependent on the type of equipment used?

A: No, use of the new digital breast tomosynthesis (DBT) codes is not dependent on the type of equipment used.

When the ACR, American Roentgen Ray Society, and Radiological Society of North America’s CPT advisors worked with the AMA’s CPT Editorial Panel to create the new codes for screening and diagnostic tomosynthesis, the codes were specifically designed to be vendor neutral. If a screening or diagnostic tomosynthesis is performed, it should be reported with the new CPT codes (77061, 77062, 77063) or the new Medicare HCPCS Level II G-code (G0279) for diagnostic tomosynthesis, regardless of which vendor’s equipment was used to perform the exam.

In an effort to reduce patient exposure further, each of the manufacturers with current approval of their DBT systems has designed a system that allows the full-field digital mammography (FFDM) planar images to be generated from the multiple small exposures of the DBT system rather than necessitating an additional exposure to acquire a FFDM planar image. Whether a FFDM planar image is derived from a single larger exposure or a series of smaller exposures, it is still a planar mammogram and should be coded as such.

Questions have also arisen regarding the combination of planar mammography and tomosynthesis. When a planar mammogram and a tomosynthesis exam are performed, both the planar mammogram and the tomosynthesis exam should be coded. This is true for both screening and diagnostic exams, and is again vendor neutral.

Q: Is breast tomosynthesis 3D?

A: Although vendors describe breast tomosynthesis as 3D, 3D is a misnomer. Breast tomosynthesis is not truly 3-D in any sense, and is not the 3D imaging as is done for CT and MR. The ACR has gone to great lengths at the CPT® Editorial Panel and the Relative Value Scale Unit Update Committee meetings to NOT use the terms 2D or 3D for that reason. Breast tomosynthesis is essentially the same as doing a group of tomograms from conventional tomography, which was historically performed as part of an IVP exam, and looking at the individual tomograms in a stacked set. That is not 3-D in the way most of us think about 3D.

Q: Is a written order required for tomosynthesis now that there is a billable service?

A: An order for breast tomosynthesis, as described by the new breast tomosynthesis add-on codes, is not required and would fall within the Ordering of Diagnostic Tests Rule exception. However, when breast tomosynthesis is used, the breast tomosynthesis procedure should be documented in the report. The breast tomosynthesis add-on codes fall within the test design exception described inMedicare Benefit Policy Manual, Chapter 15 , – Covered Medical and Other Health Services. See section 80.6 for the latest guidelines on the Ordering of Diagnostic Tests Rule.

Q: Must I use the new XE, XP, XS and XU modifiers in place of modifier 59 as of January 1, 2015?

A: No, you may continue to use modifier 59 during the transitional period that begins on 1/1/2015. CMS will not require the use of the new modifiers until such time as it publishes additional guidance.

As noted in July/August 2014 ACR Radiology Coding Source and as CMS notified the ACR, it will be implementing CR#8863 (Specific Modifiers for Distinct Procedural Services) on January 5, 2015, effective January 1, 2015. CR 8863 states that four new more selective modifiers are available and describes the general situations in which they can be used. However, CR#8863 also noted that, at the present time, modifier -59 may continue to be used. The CR system instructions specify that Medicare edits will initially consider the –X{EPSU} modifiers to be equivalent (interchangeable from an edit perspective) with modifier -59, a situation which will also allow providers time to slowly adjust to the new modifiers. CMS wrote these instructions in order to allow a transition period as additional coding advice and educational programs are developed. As with all codes and modifiers, until such time as additional coding advice is published, providers should take the new modifiers at face value. The –XE modifier, for example, defines a separate encounter, so it should only be used when services provided at multiple encounters are reported. CMS intends to promote transparency and consistent coding by pairing additional education and guidance with any future edit changes that depend on these new modifiers, so additional guidance on their appropriate use with specific codes and specific situations will be forthcoming.