Breast and colon cancer are the leading causes of cancer deaths in the United States right after lung cancer. However, there are screening procedures available to diagnose these cancers in the earliest stages. This article provides instructions for coding the diagnoses and procedures for screening malignant neoplasm of the breast and the colon. Before reviewing these instructions, let's first review the official guidelines for coding the diagnoses for all screening procedures.
Screening is the testing for diseases in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease. If testing is performed because the patient has a sign or symptom, the sign or symptom code is used to explain the reason for the test, not the screening code.
A screening code may be the first listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an encounter for other health problems. If a condition is discovered during the screening, the code for the condition may be assigned as an additional diagnosis.
The following V code categories are reported to indicate that a screening exam is planned. A procedure code is also required to confirm that the screening was performed.
V28 Antenatal screening
V73-V82 Special screening examinations
When the reason for performing a test is because the patient has had contact with, or exposure to, a communicable disease, the appropriate code from category V01, Contact with or exposure to communicable diseases, should be assigned, not a screening code.
Every woman is at risk for developing breast cancer, and the risk increases with age. According to the Center of Disease Control and Prevention (CDC), approximately 94 percent of breast cancers are diagnosed in women older than age 40. Mammography is the best available way to detect breast cancer early, when it is most curable. Timely screening can reduce breast cancer mortality in women 40 and older by 17 percent to 30 percent. The National Cancer Institute (NCI) guidelines for screening mammography recommend that asymptomatic women 40 years or older be screened every 1 to 2 years and women aged 50 or older be screened every 1 to 2 years. NCI further recommends that younger women who are at higher risk for developing breast cancer consult with their physician regarding screening mammography and the frequency of such screenings.
Diagnostic mammograms differ from screening mammograms. Screening mammograms are for patients without documented problems. Diagnostic mammograms are performed when there is a problem such as a breast mass, pain, discharge, etc. Code any positive findings found on the diagnostic mammogram as the first listed diagnoses. If there are no reported findings, assign the reason for the test.
The diagnoses codes for encounters for screening mammogram are V76.11 and V76.12.
V76.12, Special screening for malignant neoplasm, other screening mammography
Example: A healthy 40-year-old woman presents to the radiology department for a screening mammogram. The patient has no symptoms or known risks for breast cancer. Assign code V76.12.
V76.11, Special screening for malignant neoplasm, screening mammogram for high-risk patients.
The following codes may be assigned with code V76.11 to identify why the patient is considered to be at high-risk.
V10.3, Personal history of malignant neoplasm, breast
V16.3, Family history of malignant neoplasm, breast
V15.89, Other specified personal history presenting hazards to health, other
Example: A woman with no symptoms is referred to the hospital for screening mammogram. The patient is considered high risk for breast cancer secondary to family history of breast malignancy in the mother and sister. Assign code V76.11 followed by code V16.3.
If a condition is found during the screening, then the code for the condition may be used as an additional diagnosis. The rationale for this is that even though a condition is found during the mammography, the visit is still considered a screening.
For Medicare services, diagnosis codes V76.11 and V76.12 must be the first listed diagnosis on all encounters for screening mammography services. However, effective Oct. 1, 2006, this requirement will change to allow the reporting of any applicable diagnosis code as a primary diagnosis on claims containing other services in addition to a screening mammography. Continue reporting diagnosis codes V76.11 and V76.12 as the first listed diagnosis codes on claims that contain only screening mammography services.
A mammogram is a low-dose X-ray of the breast that can find lumps that are too small to be felt during a breast examination. The breast is compressed firmly between two planes and pictures are taken. This spreads the tissue and allows for a lower X-ray dose. A screening mammogram is used to detect breast changes in women who have no signs of breast cancer. When the patient has signs or symptoms of a suspected disease then a diagnostic mammogram is performed and coded instead.
A screening mammogram is inherently bilateral and is reported with codes 76092 and G0202.
76092, Screening mammography, bilateral (two view film study of each breast)
G0202, Screening mammography, producing direct digital image, bilateral, all views
Code 76083, Computer aided detection (CAD); screening mammography, may be assigned as an additional procedure code when it is performed in addition to the primary procedure. The additional CAD code indicates that a laser beam was used to scan the mammography film and then the image was converted to digital data for computer analysis.
As mentioned earlier, if a condition is discovered during the screening, then the code for the condition may be used as an additional diagnosis. In this instance, if the radiologist performing the mammogram orders additional films based on the condition discovered during the screening mammogram, both may be coded. When a screening mammogram is converted to a diagnostic mammogram on the same day append modifier GG, Performance and payment of a screening mammography and diagnostic mammography on same patient same day, to the diagnostic mammography code. Modifier GG indicates that the test changed from a screening test to a diagnostic test. If not performed on both breasts, it is also important to append the appropriate anatomic modifier, RT or LT, to indicate which side the diagnostic mammogram was performed on.
Colorectal cancer is one of the leading causes of cancer deaths in the United States. Approximately 56,290 people died from colorectal cancer, and 145,290 people were newly diagnosed with the disease in 2005. Colorectal cancer is usually found in people ages 50 and older. Therefore, screening for colorectal cancer for people ages 50 and older is strongly recommended. Colorectal cancer can be prevented and treated through routine screening and early detection.
The ICD-9-CM diagnosis code for an average risk patient presenting for a screening colonoscopy is V76.51, Special screening for malignant neoplasm, colon. A screening colonoscopy may also be performed for patients considered to be a high risk for colon cancer.
Code V76.51 should be the first listed diagnosis code if the reason for the visit is specifically for the screening exam. For high risk patients, the appropriate family or personal history V code identifying the risk should also be assigned. As with screening for malignant neoplasm of the breast, if a condition is discovered during the screening then the code for the condition may also be assigned as an additional diagnosis.
If the colonoscopy is performed because the patient has a sign or symptom, the sign or symptom code is used to explain the reason for the test, not the screening code. However, if positive findings are discovered during the diagnostic colonoscopy assign the code for these findings instead.
Colorectal cancer screening tests and procedures can be used alone or in various combinations and include fecal blood test, barium enema, flexible sigmoidoscopy and colonoscopy. Colonoscopy screening procedures are discussed here.
A colonoscopy is considered the gold standard for colorectal cancer screening. After the patient's bowel has been prepped, the physician inserts the colonoscope-a long, thin, flexible lighted tube-through the anus and advances the scope through the colon past the splenic flexure. The lumen of the colon and rectum is visualized. Most polyps and some cancers can be removed during this procedure. The colonoscope is then withdrawn.
HCPCS Level ll codes G0105 and G0121 should be reported for Medicare outpatients requiring screening colonoscopy for colorectal cancer.
G0121, Colorectal cancer screening, colonoscopy on individual not meeting criteria for high risk
G0105, Colorectal cancer screening, colonoscopy on individual at high risk
According to Medicare, a patient is considered to be at high risk if he or she has any of the following risk factors: close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp; family history of familial adenomatous polyposis; family history of hereditary nonpolyposis colorectal cancer; personal history of adenomatous polyps; personal history of colorectal cancer; inflammatory bowel disease, including Crohn's disease and ulcerative colitis.
Screening colonoscopy for non-Medicare patients is coded with 45378, Colonoscopy, flexible, proximal to splenic flexure, diagnostic.
If an abnormality is found during a screening colonoscopy and results in a therapeutic procedure, then the appropriate diagnostic colonoscopy CPT code (45379-45392) is used instead of codes G0105, G0121 or 45378. Therapeutic procedures include biopsy, polypectomy, etc.
Review the CCS Prep column titled, "Understanding How to Code Colonoscopies" for instructions on coding therapeutic procedures.
Example: A patient is seen in the outpatient clinic for screening colonoscopy due to family history of colon cancer. The colonoscopy revealed a colonic polyp that was removed by snare technique. Assign CPT code 45385.
For Medicare OPPS coding, when a screening colonoscopy is attempted but due to extenuating circumstances cannot be completed, code G0105 or G0121 should be reported with either modifier -73 or -74 as appropriate.
1) A patient with a family history of colon cancer is seen in the hospital outpatient department for a screening colonoscopy. During the procedure, two polyps are discovered and removed by electrocautery snare. How should the diagnoses and procedures for this case be coded?
a. V76.51, V16.0 45385
b. V76.51, 211.3, V16.0, 45385
c. 211.3, V16.0, 45385
d. V76.51, 211.3, V16.0 G0105
2) An asymptomatic 65-year-old woman has a screening mammogram, which revealed a breast mass. The physician scheduled the patient for follow-up biopsy of the breast mass at a later date. How should the diagnoses and procedures for this case be coded?
a. V76.12, 611.72, 76092
b. 611.72, 76092
c. V76.12, 76092
d. V76.11 611.72, 76091
3) An asymptomatic 70-year-old woman with a family history of breast cancer has a screening mammogram that reveals a right breast mass. As a result of the positive finding, a diagnostic mammogram of the right breast with direct digital image is then performed. How should the diagnoses and procedures for this case be coded?
a. V76.11, 611.72, 76092
b. 611.72, 76092, 76083GG, G0206
c. V7611, 611.72, V16.3, 76083, G0206
d. V7611, 611.72, V16.3, 76083GGRT, G0206
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services at HSS, an Ingenix company (www.hssweb.com). HSS specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the AHA.
CPT is a registered trademark of the AMA.
Answers to CCS Prep!: 1) b. Assign code V76.51, Special screening for malignant neoplasm, colon, as the first-listed diagnosis because this was a screening colonoscopy. V16.0 is assigned for the family history of colon cancer. Assign code 211.3, Benign neoplasm of colon as an additional diagnosis. Procedure code 45385 is reported instead of one of the screening colonoscopy codes because a definitive procedure, snare removal of polyp, was performed; 2) a. Assign diagnosis code V76.12 to indicate the screening for malignant neoplasm of breast and code 611.72, Lump or mass in breast, as an additional diagnosis to identify the X-ray finding of the breast mass. Procedure code 76092 is assigned to identify the performance of the screening mammography; 3) d. Assign diagnosis code V76.11 to indicate that the breast cancer screening is being performed on a high risk patient. Secondary diagnosis codes V16.3, family history of breast cancer and 611.72, lump or mass in breast are also assigned. Procedure code 76092 is reported for the bilateral screening mammogram. Procedure codes 76083 and G0206 are assigned for the diagnostic mammogram. Modifiers GG and RT are appended to code 76083 to indicate that the screening mammogram was converted to a diagnostic mammogram of the right breast.