Oncology & Hematology Coding Alert

Question: If a patient is in remission for ovarian cancer, with no evidence of disease, but the doctor performs CT scans every four to six months to check for recurrence, is there a diagnosis code we can use to prove medical necessity to Medicare?


Florida Subscriber

Answer: Unfortunately, you'll have a hard time proving medical necessity for this service. The correct diagnosis code with no evidence of disease is either
a "screening" or a "history of" code, from the V10 series (V10.43, Personal history of malignant neoplasm; ovary). Neither generally meets insurance coverage requirements.

Caution: Don't be tempted to assign V71.x (Observation and evaluation for suspected conditions not found). This V code is for cases with inconclusive symptoms that suggest a problem with a particular organ or system, though results don't match with the suspected condition.

Option: Ask the patient to sign an Advance Beneficiary Notice (ABN) agreeing to pay for the CT scan (available at www.cms.hhs.gov/medicare/bni/CMSR1312.pdf). This form states that you suspect Medicare won't pay for the service and the patient must choose whether she'll accept the service knowing she may have to pay the bill. Include an estimate of the cost and have the patient sign and date the document. Provide her with a copy for her records.

Remember these three ABN modifiers for Medicare: GA (Waiver of liability statement on file), GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit), and GZ (Item or service expected to be denied as not reasonable and necessary).

Modifier GA means you have an ABN on file, and GZ tells Medicare you don't have an ABN and you don't expect them to pay. If you have no ABN and Medicare denies the charge, you can't approach the patient for payment. Append modifier GY when you are simply filing the claim for the denial so secondary insurance will pay.

Side-note: Remember that you don't report a "history of" code for all cancers in remission. Example: For lymphoma, you would report the correct diagnosis code for lymphoma, rather than a V code.