By Melody W. Mulaik
Whether or not you can bill for post procedure mammograms is a topic that has waxed and waned over the years. Changing payer guidelines and pending regulations changes from Mammography Quality Standards Act (MQSA) has this topic back in the spotlight. From a broad coding guidance standpoint there has not been a real change since 2017, but it is important to dive into the details to ensure compliance with payer guidelines.
Before I get into the details, let me first say that it is important to review your current protocols. If your breast biopsies are performed utilizing stereotactic equipment and you never move the patient to another machine for any type of imaging, you will likely never be billing any payer for a post procedure mammogram. The documented report should clearly define everything that is being done for the patient but understanding what is occurring and why helps enlighten the coding and billing process.
Now to the details …
On the surface it seems straightforward. If you perform a post percutaneous procedure mammogram to confirm removal of calcifications and/or to check position of the localization clip, and there is supporting documentation in the radiology report, then it is appropriate for both the facility and the radiologist to bill for this service; unless the procedure was performed under mammographic guidance. The National Correct Coding Initiative (NCCI) Policy Manual states that the mammogram is bundled only if the procedure was performed with mammographic guidance.[1]
Unfortunately, it is anything but straightforward. For example, the authoritative guidance differs for hospitals and physicians for MR guided biopsies. For hospitals, the American Hospital Association (AHA) guidance differs from NCCI guidance. According to AHA Coding Clinic for HCPCS (First Quarter 2022), it is not appropriate to assign 77065 for a post-procedure mammography following placement of a breast localization device represented by CPT code 19085 to confirm placement of the localization device post procedure. This mammogram is not considered a diagnostic study and therefore cannot be represented by CPT 77065. The AHA guidance applies to all outpatient hospital facilities so hospitals should not be charging for a post-procedure mammogram following an MRI guided breast biopsy.
For physician billing the last published guidance specifically for MR was included in Clinical Examples in Radiology (Spring 2018), “CPT code 77065 is reported for the craniocaudal and true lateral diagnostic mammogram views of the left breast performed in the mammography department after the MRI procedure to verify the appropriate position of the localization wires and for surgical guidance.”
Individual payer guidelines, including Medicare Administrative Contractors (MACs) must be reviewed to ensure compliance with their guidelines. For example, Noridian Healthcare Solutions states that “It is Noridian’s interpretation that a follow-up mammogram performed post tomosynthesis-guided breast biopsy will be considered part of the procedure and not separately payable, regardless of whether the patient is brought to a different room and/or unit for the mammography … ” The policy goes on to provide specific details as to what can and cannot be billed together.
Some commercial payer policies have published guidance that addresses how the post procedure mammogram is obtained when defining coverage. For example, one Blue Cross Blue Shield payer has a policy, “Coding and Billing Guidelines for Breast Biopsies,”[2] that states the following: “If a combination stereotactic-tomosynthesis guided biopsy is performed using a separate piece of equipment (such as a prone table) and the patient is moved to another unit for a post-procedure mammogram, it is appropriate to report the post-procedure mammogram separately. If the combination stereotactic–tomosynthesis guided biopsy is performed using a standard digital breast tomosynthesis mammography unit on which the post-procedure mammogram is also obtained, it is not appropriate to report the post-procedure mammogram separately.”
And then there is the new information from MQSA. The Final Rule, published on March 10, 2023, outlined new guidelines for “Post-Procedure Mammogram for Marker Placement” that will be effective September 10, 2024. The MQSA requirements language for reporting is being revised to specifically state “As FDA described in approval of the alternative standard, if a facility makes the post-procedure examination part of the interventional procedure instead of a separately charged examination, then the examination is not subject to the MQSA quality standard requirement and need not receive an assessment (Ref. 24). Nor would it require any report separate from the report of the interventional procedure. However, when the post-procedure mammogram is logged or charged separately from the interventional procedure, this mammogram is a separate examination and requires a separate report.”
This requirement is an important distinction since many practices include the post procedure diagnostic mammogram interpretation in the body of the biopsy procedure. This new regulation will require potential changes to workflow and documentation practices.
So, in summary – can you bill for a post procedure mammogram? As with many things in coding, it depends … what modality was utilized for the biopsy? What are your payer guidelines? This is something that should be continually monitored to ensure compliance and correct billing practices.
References
1 https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-3.pdf, page 11
2 https://www.bcbsnd.com/providers/policies-precertification/reimbursement-policy/coding-and-billing-guidelines-for-breast-biopsies
