There are several reasons to offer mammography in a freestanding imaging center, although profits are not usually one of them. Mammography brings decision-makers—women—to the center and many payors are beginning to demand a full range of imaging services from a site before letting it into their networks. And while many practices dismiss mammography as a loss leader, with close attention to billing and collections, providers can maximize breast imaging revenue, according to Lawrence W. Bassett, MD, professor and director of the Iris Cantor breast center at UCLA, who presented at the recent Society for Breast Imaging meeting in Las Vegas.

Here are the basics: for every examination performed, there must be an ICD-9 code representing an appropriate clinical indication for the exam, and an appropriate CPT code, which indicates what kind of examination was performed.

There are just three CPT codes for mammography: CPT 76090=unilateral diagnostic mammogram; CPT 76091=bilateral diagnostic mammogram; and CPT 76092=screening mammogram. But there are different ICD-9 codes for screening and diagnostic mammography. The V codes are used for screening: V76.11 is used to indicate a screening examination for a high-risk patient and V76.12 is used to indicate screening for breast cancer, not a high-risk patient. Examples of ICD-9 codes for diagnostic examinations include 174=malignant neoplasm; and 793=nonspecific abnormal findings on radiological or other breast exams; additional codes for diagnostic mammograms and ultrasound are 611.72=lump or mass; 611.71=pain; 610.0=cyst; 611.3=fat necrosis; and 612=benign neoplasm.
Problems arise when there is a disconnect between the ICD-9 and the CPT. In other words, most payors will not accept “asymptomatic woman with no risk factors” as justification for a diagnostic mammogram.

Bassett offered the following tips to maximize reimbursement:

• Engage everyone — schedulers, receptionists, technologists, and radiologists—in the effort to assure that the indication is an acceptable reason for the test.

• Schedulers are the key to obtaining correct information from referring offices to ensure that the ICD-9 is legitimate for the procedure.

• Implement user-friendly computer ordering programs designed to accept appropriate requests only.

• Develop an easy-to-use requisition form for referrers that includes a checklist of procedures and symptoms: law mandates a faxed or signed referral for the performance of a diagnostic mammogram with the appropriate diagnosis ICD-9 code.

• Meet with referring physician staff on how to order exams.

• Institute prior authorization procedures at the time of ordering.

• Be sure to have the patient fill out a form explaining why they are seeking medical attention.

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Achieving the Improbable