A Surefire Strategy for Male Mammogram Claims

Hint: Don't rely on your diagnosis codes
While Medicare often covers diagnostic mammography for male patients with symptoms of breast cancer screening mammograms are another story. Your best bet is to have male patients sign an ABN before you perform a screening mammogram.

TV announcer Rod Roddy the famous voice of "The Price Is Right " died in October of colon and breast cancer prompting many men to wonder whether breast cancer could happen to them. Because Roddy's death publicized the fact that 1 500 men each year are diagnosed with breast cancer your radiology clinic may soon begin fielding calls from men interested in getting screened for the disease.
Screening Mammos Are Male-Exempt
Most local medical review policies (LMRPs) recommend V76.12 (Other screening mammogram) for screening mammograms (76092 Screening mammography bilateral [two view film study of each breast]). The carrier may or may not pay for this service however because CMS covers annual screening mammography for "All women age 40 and over and one baseline screening mammography for women between the ages of 35 and 39."
 
"Medicare does not cover screening mammography on males by statute " says Jeff Fulkerson BA CPC CMC certified coder for the department of radiology at The Emory Clinic in Atlanta.

If you perform a mammogram on a male patient in the future you should ask him to sign an advance beneficiary notice (ABN) and append modifier -GA (Waiver of liability statement on file) to 76092 Fulkerson says.

If you do not obtain an ABN he says you should append modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to 76092. "By adding modifier -GY you are telling the carrier that you know that the service is not covered by statute and do not expect reimbursement " Fulkerson says. "How your local carrier wants the provider to handle claim filing for this type of exam may vary."
You Can Collect for Diagnostic Mammos
If you perform a diagnostic mammogram on a male patient (76090 Mammography; unilateral) or 76091      (... bilateral) your practice should document a meticulous patient history because most male patients referred for diagnostic mammography actually have signs and/or symptoms that support the performance of a diagnostic mammogram (for example mass nipple discharge or pain with or without swelling). "History of a mother with breast cancer usually is not sufficient " says Candace Ryan coding supervisor at Radiology Consultants in Denver. "You need a more comprehensive reason for the mammogram than that."

In such cases you should report the appropriate ICD-9 code(s) for the signs and symptoms. "Most carriers cover diagnostic mammograms for males using the same symptoms conditions and diagnoses that are........

Code Most GERD Tests With 91034, 91010

Make sure you document other treatments on manometry, pH study claims

When your gastroenterologist suspects that a patient may have gastroesophageal reflux disease (GERD), a trial of reflux medication or an endoscopy will usually confirm the condition.

If normal methods don't work, the gastroenterologist may choose to perform an esophageal manometry and/or a pH monitoring to check for GERD in the patient, says Ann M. Plansky, CCS-P, MBS, of Woodland Clinic in Manitowoc, Wisc.

Coding for these advanced GERD tests not only requires CPT knowledge; you also have to know who owns the equipment you're using and whether your payer will want a modifier on the claim.

Follow us for some expert advice on coding in several GERD-testing scenarios.

Manometry Only? Use 91010 - Usually

If a patient reports to your office with symptoms that could indicate GERD but doesn't have typical endoscopy findings or improvement with acid-suppression medication, the gastroenterologist may try other testing methods to determine the patient's condition, says Margaret Fisher, CCS-P, of Tacoma Digestive Disease Center/Tacoma Endoscopy Center in Washington.

Exceptions: You'll report most manometric studies with 91010, but there are separate CPT codes for special manometries. If your physician performs a manometry:

• with a stimulant, report 91011 (... with mecholyl or similar stimulant) instead of 91010 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study).
  
• with acid perfusion, report 91012 (... with acid perfusion studies) instead of 91010.

Choose 91034 for pH Monitoring

Your gastroenterologist may not choose a manometric study to check for GERD; in some instances, the physician opts for pH monitoring instead.

Heads-up: Anyone who has yet to code for a pH study this year should remember: There is a whole new way to report the procedures. Regardless of how long the study
takes, you should code all catheter pH monitoring sessions with new code 91034 (Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation), Plansky says.

Last year, you would have reported pH studies with 91032 (Esophagus, acid reflux test, with intraluminal pH electrode for detection of gastroesophageal reflux) and 91033 (... prolonged reading), depending on the encounter. These codes are not in CPT 2005, however, so do not use them at all.

For example, a patient reports for a pH study to identify the cause of acute esophagitis. The gastroenterologist performs a seven-hour pH monitoring session. On the claim, you should:

• report 91034 for the pH testing.
• attach ICD-9 code 530.12 (Acute esophagitis) to 91034 to represent the patient's symptoms.
• document any previous treatments or tests the gastroenterologist performed on the patient for the condition.

Both Tests in Same Session Possible

In certain instances, performing a manometry and pH study during the same patient encounter makes sense, Plansky says. When her gastroenterologist performs both tests in the same session, Plansky reports 91010 for the manometry and 91034 for the pH monitoring.

We have billed [91010 and 91034 together] to our local Medicare carrier and other commercial insurance companies" and have not had any problems with payment " Plansky says.

Fisher also reports 91010 and 91034 without any modifiers but she offers this tip: "Report 91010 on the date of service and 91034 the next day or whenever the probe is removed " she says.

That way you can avoid problems that can befall claims featuring two CPT codes with the same date of service.

Observe Modifier -26 -TC Exceptions

When reporting either 91010 or 91034 you must remember that you cannot get paid for the entire code unless your office owns the equipment. If your gastroenterologist is using another facility's equipment to perform the manometry you should attach modifier -26 (Professional component) to the CPT code.

For example the physicians at Fisher's practice have their own equipment set up in an ambulatory surgery center. When they perform esophageal manometries or pH studies in that ASC Fisher reports the encounters without any modifiers.

However when the physicians treat Medicare and Medicaid patients at local hospitals Fisher reports the encounters with modifier -26 attached to indicate that her practice only deserves payment for the professional service. These payers do not reimburse her practice for the facility fee she says.

In those instances the hospital will report the appropriate APC code for Medicare or Medicaid patients or will use the CPT code with modifier -TC (Technical component) for the technical component only."