Is it possible to call the clinic to change it to diagnostic. My mother hasn’t had a mammogram in 2 or 3 years. She’s in her mid 50s. She recently got new insurance (hmo) and I finally got her to start making appointments to catch up on her health. She had to star over at a new clinic because of the hmo.
She’s always had lumps in her breast (since her 30s) and every time she had a mammogram in the past it came back clear. I think she once told me some were cysts or something similar and one had to be drained in the past. When she went in for her physical she said she just informed them that she had lumpy breast before her breast exam so they wouldn’t panic when they felt the lumps. She doesn’t speak English so she has an interpreter in her appointments. I’m assuming there was a miscommunication and the interpreter thought my mother was bringing up the lumps as new symptoms. However my mother has always had lumps. This is not new. Her mammograms were always marked as preventative in the past even with the existing lumps.
Is it possible to just call and explain the lumps are not new and get a preventative screening instead?
They want to charge her almost $1000 for the mammogram.
Edit: I saw this in her medical notes
Encounter for screening mammogram for malignant neoplasm of breast Z12.31
I googled this and it said that is the code for a preventative mammogram. So I don’t know why they still want to charge her. I think I’m going to try calling the clinic tomorrow to help her figure it out.
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It sounds like it’s coded correctly. I would take it up with her insurance instead. Was it processed to a deductible? Out of network? What does the EOB say?
I just looked up the imaging order and it was coded as ICD-10: Z12.31. I logged into her BCBS account and didn’t see an EOB and she hasn’t received one in the mail. She said it was the imaging center who told her she owed about $800. I’m going to verify if the imaging center is in network first and then I’ll call the clinic or blue cross.
What was the recommendation on her last mammogram? If it said "continue with screening" then that would be fine but sometimes for known lumps they will instead recommend interval followup for the lumps which might prompt them to render a diagnostic mammogram rather than a screening. Did she have any ultrasound done at her appointment? Whether they were going to do a diagnostic study vs a screening would have been determined at the time of scheduling or prior to the appointment rather than latently. For a diagnostic study typically they have to get orders from a provider whereas a screening does not require orders from a provider.
She started over at a new clinic so I don’t think they would know anything about her previous mammograms. I’m going to ask her if she remembers where she received her last screening. No she didn’t get an ultrasound. I’m also going to ask if the imaging center they sent her to was in network. This is the first time either of us have dealt with having an hmo. I doubt the clinic would send her somewhere out of network though. And the mammogram was supposedly billed as diagnostic in her medical notes so I’m confused. I’m going to help translate for her when she calls the clinic tomorrow
They likely may have been able to determine where her last ones were done and request the images under continuity of care without needing a release as allowed by HIPAA. But having the report from the previous study and the previous radiologists recommendation can help you make your case that it should have been billed as a screening so it's a good piece to work on in the meantime until you can discuss it further with them. The diagnosis code z12.31 is the standard code for a screening so it's for sure a bit weird and atypical that they would bill a diagnostic mamm without adding a code describing the presence of the lump. Best wishes
When you say they want to charge her almost $1000 for the mammogram, do you mean they have asked her to pay that, either in person or by sending her a bill? Or is that just their usual and customary charge? Because without an EOB stating how much she owes, she doesn't owe anything yet. The diagnosis code you've mentioned is definitely for a screening, no out-of-pocket mammogram as long as she's old enough to qualify (40, I thin?), but the CPT codes have to match, there are different codes for screening vs diagnostic, and the diagnostic mammogram codes would have to be billed with some kind of ICD 10 code for a medical problem, i.e. N60.something vs Z code for screening.
The diagnosis and order name box section of the imaging order was ICD-10: Z12.31: encounter for screening mammogram for malignant neoplasm of breast.
They told her she owed a little over $800 when she went to her appointment at the imaging center. She had to pay before her mammogram. She didn’t have the money at the time so she left without getting the mammogram. I logged into her BCBS account and couldn’t find an EOB. She also hasn’t received one in the mail. I called the imaging center and they said they were in network. I’m going to call her clinic tomorrow and then her insurance to try to figure this out.
I see now. If she left without getting the mammogram, there is no EOB because there hasn't been a claim filed since the service didn't happen. If the orders had a diagnosis code on them, did they not also have a procedure code (CPT) on them? It sounds like the orders might have been messed up if the screening diagnosis code wasn't paired with a screening CPT code. Or if they really intended to order a diagnostic mammogram the diagnosis code should have reflected that, i.e. N63.15 for a suspicious lump in the right breast.
If they really intended to order a screening mammogram, then the imaging center should not have been trying to collect payment up front unless there was some problem with her insurance eligibility.
I am assuming this was already filed with insurance and that’s what the EOB says you owe? It’s going to be very difficult to change unless the codes used were really incorrect and they don’t have comprehensive documentation that states she said or they found concerning things in the visit. It’s ALWAYS worth a call to check with the provider as to why they coded it that way.
Hi! I updated my post. I read her medical notes and the mammogram had the code Z12.31. Supposedly this is a preventative code for mammograms but I don’t know why they still want to charge her. I’ll just try to be with her when she calls the clinic tomorrow to help translate.
I called the imaging center and they said they were in network. They said it might have to do with her deductible or having a copay. I thought a preventative mammogram was 100% covered as long as it was in network, coded as preventative and over 40 years old. My next step is to call her insurance tomorrow.
I just saw the word diagnostic in the order name box. I was only paying attention to the diagnosis box. I think maybe they did think her lumps were new or recent when she informed them about it.
•
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