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Diagnostic v. screening mammogram based on referring physician’s order

APCs Weekly Monitor, August 5, 2005

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Diagnostic v. screening mammogram based on referring physician's order

(Note: The July 1 APCs Weekly Monitor answered the below question, but due to a number of requests for clarification and greater specificity an expanded answer is included this month).

QUESTION: When a non-symptomatic mammography patient has a previous history of breast cancer, do you charge the patient for a screening mammogram or a diagnostic mammogram?

ANSWER: There is much confusion regarding screening v. diagnostic mammograms. Generally, you can consider performing a diagnostic mammogram on a patient who has a history of breast cancer, however the exam should be performed and coded as either screening or diagnostic based on the referring physician's order and nothing else. (The number of views taken does not necessarily determine whether it is screening or diagnostic).

If a physician orders a screening mammogram, code and bill for a screening mammogram. If the physician orders a diagnostic exam, code and bill for a diagnostic exam. There are two exceptions:

1. When the referring physician orders a screening and the radiologist finds an abnormality. At this point, the radiologist can proceed with a diagnostic mammogram.

2. When the patient complains of a breast problem immediately prior to the exam. The radiologist typically changes the mammogram from screening to diagnostic.

If there is a question as to whether the physician has placed the correct order based on the criteria established by CMS for screening v. diagnostic exams, your best option is to contact the referring physician, let him or her know that the patient in question meets the criteria for a diagnostic mammogram, and request that he or she send along a corrected order. You can also educate physicians by giving them order forms to fill out that indicate which patients meet the criteria for screening exams, and which ones you must categorize as diagnostic.

The following are some other steps to take that will educate physicians, says Stacie Buck, RHIA, LHRM, vice president of Southeast Radiology Management in Stuart, FL.

Instruct physicians to include a clear indication--on all orders--of the type of mammogram they are requesting. Even though Medicare does not require a physician's order or referral for payment of a screening mammogram, physicians who routinely write orders or referrals for mammograms should clearly indicate the type of mammogram (screening or diagnostic) the patient is to receive.

Beyond the type of screening ordered, the referring physician should also indicate the applicable ICD-9-CM diagnosis code that reflects the reason for the test and the date of the last screening mammogram. Having this information will allow the radiologist to ensure that the beneficiary receives the correct screening or diagnostic service.

It may also be helpful to put together a bulletin or cheat sheet that lists the criteria for screening and diagnostic mammograms. Taking this step can help referring physicians order the exams that are most appropriate. Such a bulletin should include CMS criteria as well as any alternative criteria that state Medicare or Medicaid carriers or other third-party payers use.

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