Corporate Compliance

Charge diagnostic mammogram for patient with history of cancer

Compliance Monitor, July 15, 2005

Q: 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?

A:There is much confusion regarding screening v. diagnostic mammograms, but the issue is simple. Generally a patient with a history of breast cancer can be considered for a diagnostic mammogram, 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 he or she orders a diagnostic exam, that is how you should code and bill for that exam. An exception though, is when the referring physician orders a screening and the radiologist finds an abnormality. Then he or she can proceed with a diagnostic mammogram. The referring physician ultimately makes the decision as to whether a screening or diagnostic mammogram is appropriate.

If there is a question as to whether the physician has placed the correct order based on the criteria established by Centers for Medicare & Medicaid Services (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 must be categorized as diagnostic.

The following are some other steps to take to 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, whether screening or diagnostic. 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 used by state Medicare or Medicaid carriers or other third-party payers.

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