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When it comes to medical coding, accurate coding is essential for maintaining the reimbursement, compliance, and documentation of care provided to patients. Of all preventive services, the billing of screening mammography is the most common radiology procedure performed. Correct pairing of CPT code 77067 for screening mammography with ICD-10 diagnosis codes must be ensured to reduce the risk of denials, delays, and compliance headaches. Providers, coders, and billing specialists alike need to have a clear understanding of the differences between CPT 77067 along with instruction on how to properly pair it with ICD-10 codes.
Defining CPT Code 77067
The Code 77067 is a CPT code for billing purposes and is defined as Bilateral Screening Mammography with Computer-Aided Detection (CAD) when applicable. This is used for screening at the preventive level and is performed to patients who are not showing signs or symptoms of any breast disease. The aim of this is to detect breast cancer as early as possible and is done mainly on women who are asymptomatic, but it can also be done on men when it is clinically appropriate. A diagnostic mammogram is performed when there is a specific issue to investigate, while screening mammograms are done in an effort to detect problems before they progress.
Importance of Correct Usage
Wrong use of CPT 77067 can lead to claim denials or incorrect payments. A doctor can bill CPT 77067 while also including a diagnosis of breast pain or a breast lump, but the insurer can deny the claim. It means the breast needs to have a diagnostic mammogram. The diagnostic mammography codes (77065 or 77066) are more appropriate in these situations. CPT 77067 must be reported accurately on an insurance claim to meet the rules of the insurance companies and for coverage of preventative services since they are 100% covered in most plans.
Understanding ICD-10 Codes for Screening Mammography
ICD-10 Codes and Medical Billing
ICD-10 codes specify the necessity for a procedure. CPT codes tell you what service was performed and ICD-10 codes tell you why it was done. While billing CPT 77067, the ICD-10 code must state that it was a screening. Mismatched intent of a procedure from incorrect diagnosis coding leads to denials and/or audits.
Common ICD-10 Code Used with CPT 77067
The ICD-10 code that most commonly pairs with CPT 77067 is Z12.31, which describes an encounter for screening mammograms for malignant neoplasm of the breast. This code describes preventive screening and therefore supports the medical necessity of CPT 77067. This combination is used by Medicare, Medicaid, and commercial insurance payers as long as it is correct.
CPT 77067 and ICD-10 Pairing Rules
Matching Screening with Screening Diagnosis
The most important rule in CPT 77067 is making sure that the diagnosis is screening and not symptomatic. When the patient is without any symptoms and is having a routine screening, the diagnosis must indicate screening.
If a patient is expressing symptoms, for example, pain, a lump, discharge, or any previous abnormal imaging, then the procedure is not considered screening any longer. In those cases, CPT 77067 should be replaced by a diagnostic mammography code. Diagnostic CPT coding is one of the most frequent billing errors resulting in significant financial loss.
Importance of Medical Documentation
Documentation that justifies the service of a screening mammogram must include the provider’s notes that the patient is without symptoms and is presenting for a screening as part of a routine examination.
The documentation should include details of the preventive visit, patient’s age, and applicable risk factors. Documentation should confirm there are no active complaints related to the breast. Good documentation helps the provider defend themselves in an audit, and is helpful for winning the insurance case.
Common Coding Mistakes and How to Avoid Them
Symptom Coding Rules and CPT 77067
A frequently used illustration of coding error is CPT 77067 with an ICD-10 code that communicates symptoms associated with a breast condition such as a breast lump or breast pain. This is contradictory coding, as screening mammograms are for people without symptoms at all. There must be clear documentation by the provider to substantiate that there are no symptoms prior to coding CPT 77067.
Screening vs. Diagnostic Services
One more recurring coding mistake is the confusion between a screening mammogram and a diagnostic mammogram. A patient is first seen for a screening mammogram, but if a suspicious abnormality is detected and further mammographic views are taken, those additional images are considered diagnostic.
In situations like this, the coding strategy for the order of services performed should contain a diagnostic purpose, appropriate modifier with a correct CPT code to prevent billing errors.
Failure to Verify Insurance Coverage Requirements
Not all insurers require screening and diagnosis codes to be done at specific intervals. Some will deny coverage if a patient is diagnosed without a relevant code. Reviewing an insurer’s guidelines prior to submitting a claim will result in fewer denials.
Reimbursement Considerations
Preventive Service Coverage
Screening mammograms under CPT 77067 are categorized as preventative care. Most insurance companies, including Medicare, provide coverage for screening mammograms if billed correctly. Diagnostics that are billed incorrectly will force patients to pay.
Effect of Revenue and Coding
Efficient billing and accurate coding will result in fewer complications and a quicker return on investment. Claim denials delay payments and result in administrative work. Healthcare organizations that center on coding accuracy financially benefit.
Special Situations in CPT 77067 Coding
Screening for Patients at a High Risk
Some patients may undergo mammography screening on account of breast cancer. In such situations, other ICD-10 codes can be combined with the diagnosis of screening to indicate risk factors. The primary diagnosis can still show screening even if the patient is asymptomatic.
Medicare Considerations
Medicare has rules regarding the frequency of screening mammograms and who is eligible. Appropriate usage of CPT 77067 and screening ICD-10 codes is how we adhere to Medicare’s policies for preventive services. Not adhering to Medicare rules can lead to rejected claims and audits.
Compliance and Audit Risks
Importance of Coding Compliance
The incorrect combination of CPT code 77067 and the ICD-10 code is a source of audits and compliance reviews. Audit claims ensure that the documented services match the billed services and the diagnosis code. Repeated errors can lead to fines and the requirement to pay back amounts billed.
Role of Coding Education and Training
Training coding and billing staff is the most effective way to keep errors down and stay compliant. Coders should stay up-to-date with the latest coding regulations to correctly assign CPT and ICD-10 codes. Health care organizations should also conduct routine internal audits to detect and address coding errors.
Best Practices for Accurate CPT 77067 and ICD-10 Pairing
Review Provider Documentation Carefully
Before coding, coders should review the provider documentation. Coding is correct if the mammogram is preventive and there are no symptoms. Improved communication between provider and coder is beneficial.
Use Screening Diagnosis Codes Correctly
For mammograms of a preventive nature, always use CPT 77067 in combination with screening ICD-10 codes. Do not use diagnosis codes based on symptoms unless the procedure is diagnostic. The correct diagnosis code combination means more likely correct processing of the claim.
Understand the Payer Requirements
Knowing the policies of the payer before doing the billing will almost always eliminate denials. Knowing the limitations of the insurance and the coverage rules will help ensure coding and reimbursement are correct.
Final Thoughts
The correct ICD-10 diagnosis codes and CPT code 77067 pairings are essential to ensure that billing is done correctly, reimbursement is done properly, and that regulations are adhered to. Since CPT 77067 is for screening mammography, it should be accompanied by screening diagnosis codes like Z12.31, along with the proper documentation. Staying away from mistakes like symptom-based diagnosis coding will keep claim denials and the associated loss of revenue. Those in the healthcare and billing professions who understand coding, keep good documentation, and understand payer regulations will lose valuable, costly work to a much less extent. Coding is one of the barriers to efficient functioning of revenue flow, along with control of the barriers, ensuring that the needs for good preventive care of patients are met.
Make An Appintment With A2ZFAQs
CPT 77067 refers to a patient’s bilateral screening mammography along with computer-aided detection (CAD). It is used for a patient’s preventive screening.
The ICD 10 code used the most with CPT 77067 is Z12.31. It describes an encounter for a screening mammogram for the malignant neoplasm of the breast. This diagnosis indicates the service is preventive.
CPT 77067 cannot be used if a patient has breast pain, a lump, or discharge. These situations require different CPT codes. These would be classified under diagnostic mammography CPT codes 77065 or 77066.
The most common reason for denial for claims is the ICD-10 pairing is incorrect, documentation lacking etc. for screening, the service was billed too frequently, or the symptom codes are misdiagnosed instead of a screening diagnosis code.
Most insurance plans, including Medicare, cover screening mammography CPT 77067, provided the service is paired with, and properly coded to, a screening ICD-10 diagnosis and is within the insurance frequency guidelines.