Primary Care Coding Alert

Question: I am a nurse practitioner and work with some older adults under Medicare. I am concerned because some of them have a history of heart problems and hypothyroidism and keeping their cholesterol levels in check is quite important. But Medicare wont pay for the cholesterol screening, even though the patients are at risk, unless the test is preempted by an established diagnosis. How would I know what to diagnose if they havent yet been screened? I believe the same restrictions apply to mammograms. Please explain current Medicare policy when it comes to screenings.

Anonymous Ohio Subscriber

Answer: Not more than three years ago, most important screenings were not covered by Medicare, but things are changing, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in
N. Augusta, S.C.

Although cholesterol screenings have not yet made the list of covered procedures, cervical or vaginal cancer screenings (G0101), colorectal screenings (G0106 and G0107), pelvic and clinical breast exams (G0101), flexible sigmoidoscopies (G0104) and colonoscopies (G0105) are at least being reviewed by the Health Care Financing Administration (HCFA) for inclusion in the CPT codes. The G codes are temporary and fall under the jurisdiction of the local carrier.

These preventive measures, however, carry some restrictions. Medicare considers cervical or vaginal cancer screenings and pelvic and clinical breast exams to be comparable to a level 2 E/M new patient office visit (99202). Callaway-Stradley, however, says that breast and pelvic exams are only covered every three years, but Medicare may pay for one annually if the beneficiary falls into one of the following categories:

1) is of childbearing age and has had an exam indicating the presence of cervical or vaginal cancer or other abnormality during any of the preceding three years; or

2) is considered to be at high risk for vaginal cancer as
evidenced by prenatal exposure to diethylstilbestrol
or for cervical cancer as evidenced by any of the following:

- early onset of sexual activity (under 16 years of age);

- multiple sexual partners (five or more in a lifetime);

- history of sexually transmitted disease (including HIV); or

- absence of three negative Pap smears or complete absence of Pap smears within the previous seven years.. Flexible sigmoidoscopies and colorectal screenings with a barium enema are allowed once every four years for patients 50 years or older. Colonoscopies are reserved for those at high risk for colorectal cancer. Patients may receive coverage for colorectal screenings with fecal occult blood tests once yearly if they are 50 years or older.

Medicare will cover a screening mammogram (76092) for women over 39 if at least 11 months have passed following the month in which the last screening was performed, says Thomas Kent, CMM, principal of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, Md; however, it will not be covered under Part B of Medicare. The diagnostic code V76.1 (special screening for malignant neoplasm, breast) can be used; a fifth digit (e.g., V76.11) should be used to indicate a screening mammogram for a high-risk patient.

The diagnostic mammogram (76090, unilateral; 76091, bilateral) may be done more often if there is medical necessity and merits a higher reimbursement. Sign and symptom codes, such as 611.71 (breast pain), 611.72 (breast lump or mass), 611.1 (breast hypertrophy), 610.1 (fibrocystic disease), 610.2 (fibroadenosis) and 217 (benign neoplasm of the breast), as well as diagnostic codes for family history of breast cancer are appropriate.

Finally, Pap smears (Q0091) are covered by Medicare every three years unless a physician suspects cervical abnormalities and then allows more frequent screenings. Q codes, like G codes, are temporary and are under the jurisdiction of the local carrier.

As far as suspecting a disease such as hypothyroidism based on signs and symptoms, Callaway-Stradley suggests physicians code the symptoms as the reason for undertaking a screening, such as the one to detect the thyroid stimulating hormone.