Radiology Coding Alert

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 applicable and reimbursable for female diagnostic mammography " Fulkerson says. He reminds practices to thoroughly document the medical necessity for the service in the patient's medical record.
 
If you perform a mammogram on a male patient with confirmed breast cancer report 175.x (Malignant neoplasm of male breast) instead of the 174.x series which refers only to female breast cancer.