Ob-Gyn Coding Alert

Question: Our ob-gyn wants to send a patient for tumor marker testing before she does a hysteroscopy dilation and curettage (D&C) for profuse bleeding and ovarian cysts. Patient has a family history of breast cancer and some history of ovarian cancer. The patient has Medicare, but her carrier does not cover this testing. What is a possible diagnosis (other than the obvious ones) that may allow coverage?

Kentucky Subscriber

Answer: Red flags should be waving. You cannot fix coverage with coding -- ever. To do so qualifies as fraud. Action: Obtain informed consent from the patient and have her sign an advance beneficiary notice, which informs her that Medicare may not pay for the test. She can then decide whether to have it done or not. Medicare will pay only for a CA 125 level (86304, Immunosay for tumor antigen, quantitative; CA 125) as part of the initial pre-operative work-up for women presenting with a suspicious pelvic mass (except as indicated below) or for the ongoing evaluation of chemotherapy treatment of the malignancy. Medicare will use this value as a baseline for purposes of post-operative monitoring.

Medicare does not cover a CA-125 when a patient has signs and symptoms that suggest malignancy. Medicare, however, will cover a biopsy to determine if the patient does have ovarian cancer (for instance, 58900, Biopsy of ovary, unilateral or bilateral [separate procedure]).

Medicare goes on to say that the CA 125 is also not covered for aiding in the differential diagnosis of patients with a pelvic mass as the sensitivity and specificity of the test is not sufficient.