If my dense-breasted patient would like supplemental screening after her mammogram, how should I write the order?

Mammography using 3D/tomosynthesis is the preferred primary screening modality.

Availability of supplemental screening may depend on each practice. It can be useful to ask your local radiology facility what technologies are available.

To order supplemental screening for a woman with dense breasts, the ICD-10 code typically used as the indication for women with dense breasts is R92.2, inconclusive mammogram.

The order or “upfront permission” can be written as follows:

“Digital breast tomosynthesis/3D mammogram; screening [insert MRI, contrast-enhanced mammography or ultrasound here] due to dense breast tissue.”

For a woman with dense breasts or for those at high risk of developing breast cancer (regardless of breast density), breast MRI is the most effective supplemental screening test. The CPT code for bilateral contrast-enhanced MRI is 77049.  Some facilities offer “abbreviated MRI” with direct-to-patient billing at a rate of $200-$600.

• For women unable or unwilling to have MRI, contrast-enhanced mammography (CEM) or screening ultrasound can be considered. Though there is currently no specific CPT code for CEM, code 77066 (diagnostic mammography, both breasts) is often used. The complete breast ultrasound CPT code is 76641 and must be scheduled for each breast.

Patients often prefer to have all their breast screening done in one visit. This can be scheduled with the imaging center and would require “upfront permission” (prescription).  Alternatively, MRI can be performed on an alternating 6-month schedule with a mammogram; computer modeling suggests this may be slightly more effective.

It may be possible to create a conditional, contingent order with the imaging facility or radiology department, indicating “additional testing permitted,” and/or to work with administration to add supplemental imaging to the electronic ordering system to facilitate scheduling. While supplemental dense breast screening with MRI detects more cancers than ultrasound, MRI may not be covered by insurance and is more often reserved for those women who are at high risk.