Oncology & Hematology Coding Alert

Question: An oncologist ordered a screening mammogram for a male Medicare patient with a family history of breast cancer. Which ICD-9 code should I report to prove medical necessity for this service?

New York Subscriber


Answer: The majority of local medical review policies recommend diagnostic code V76.12 (Other screening mammogram) for screening mammograms (76092, Screening mammography, bilateral [two-view film study of each breast]). But the carrier may or may not pay for this service, because CMS indicates that a screening mammogram is "a preventive procedure administered to women without visible signs of breast disease."

Therefore, many Medicare carriers, such as Cahaba Government Benefit Administrators in Georgia, state that they cover screening mammograms when the physician provides them for women.

Tip: Before billing a mammogram on a male patient, you should ask the patient to sign an advance beneficiary notice (ABN) and append modifier -GA (Waiver of liability statement on file) to 76092 (Screening mammography, bilateral [two-view film study of each breast]). The ABN informs the patient that he will have to pay for the procedure if Medicare does not. The ABN must identify the service and explain why Medicare may deny it.

 -- Answers to Reader Questions and You Be the Coder were reviewed by Linda L. Lively, MHA, CCS-P, RCC, CHBME, founder and CEO of American Medical Accounting and Consulting in Marietta, Ga.; and Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant based in New Orleans.