Radiology Coding Alert

Performing DEXA or Mammo Too Often? Prepare an ABN

Published on Mon Mar 08, 2004

Don't write off the $100-$150 that Medicare allots for 76092 and 76075

If you're researching payable diagnoses and double-checking your claims for DEXA and mammogram claims before sending them to Medicare, you're on track to getting paid -- but don't stop there.

Radiology practices often concentrate so carefully on payable diagnoses for dual-energy x-ray absorptiometry (DEXA) scans (76075-76076) and screening mammograms (76092, Screening mammography, bilateral [two-view film study of each breast]) that they forget to ensure that the patients meet frequency guidelines. And without an ABN on file, you can't even attempt to collect payment from a Medicare patient.

Wait a Year and a Day for Screening Mammograms

Most payers won't reimburse a screening mammogram unless 366 days have passed since the patient's last screening. Radiology practices are usually careful to double-check whether the allotted time has elapsed before they schedule a patient's mammogram.

Problems generally occur when patients come from other facilities and don't recall when they had their most recent mammograms.

If you are unable to locate the patient's prior records, you should ask the patient to sign an ABN just in case a year hasn't passed since her last mammogram. "This is especially true for a self-referred patient who comes for a screening without a physician's order," says Jeff Fulkerson, BA, CPC, CMC, certified coder in The Emory Clinic's department of radiology. Some patients will sign the ABN and go ahead with the procedure, either because they are confident that a year has passed since their last screening or because they simply don't want to reschedule the appointment and come back another day.

Report the screening mammogram (76092) to Medi-care with ICD-9 V76.12 (Other screening mammogram) as the diagnosis code. In addition, you should append modifier -GA (Waiver of liability statement on file) to 76092. This modifier tells the carrier that the patient has signed an ABN and knows that Medicare might deny the claim.

Remember that you should never use "blanket" ABN forms -- when your practice asks all DEXA (or other procedure) patients to sign ABNs "just in case." You should maintain a clear statement of the conditions that prompted your practice to obtain the ABN.

Some patients feel uncomfortable signing ABNs. As an alternative, your practice can offer to reschedule any tests with time limits related to repeat testing, or until you can verify when the patient received her last test.

Guidelines Vary for Follow-Up DEXA Scans

Unlike mammography, DEXA scans (76075, Dual- energy x-ray absorptiometry [DEXA], bone density study, one or more sites; axial skeleton [e.g., hips, pelvis, spine]; or 76076, ...appendicular skeleton [peripheral] [e.g., radius, wrist, heel]) aren't subject to concrete frequency guidelines for all patients. Depending on your patient's specific condition, she may be eligible for a follow-up scan after six months -- or she may have to wait another full year before she's entitled to reimbursement for another scan.

Blue Cross and Blue Shield of Arkansas, for example, allows follow-up DEXA scans every six months for the following indications:

Study of patients with hyperthyroidism or asymptomatic hyperparathyroidism. Those with low bone mass with an increased risk of severe skeletal disease may be considered for earlier surgery.

Evaluation of patients receiving long-term physiologic doses of corticosteroids to see if low bone mass is present.

The same Medicare carrier limits follow-up DEXA scans to once every 12 months for these conditions:

to determine if pharmacologic therapy is indicated, or a change in therapy is warranted

other bony x-ray abnormalities suggesting osteopenia in order that a decision may be made regarding further diagnostic evaluation and treatment.

If your patient doesn't meet these frequency guidelines, or if you're not sure whether she does, you should ask her to sign an ABN. "In these instances, we advise the ordering physician that Medicare may not allow payment for the procedure and that we will be asking the patient to sign an ABN," Fulkerson says.

If ordering physicians routinely order nonmedically necessary services and Medicare denies payment, some practices eventually invoice the ordering physician. "We will submit an invoice to a facility that continues to order exams without appropriate medical necessity for each exam we have to write off," says Lori Nelson, CPC, RCC, coding and billing supervisor at Radiology Associates in Rapid City, S.D.

"This doesn't happen often, but it gets everyone's attention, and those physicians work much harder to provide the medical necessity and/or the ABN."
Medicare's Policy on ABNs

Medicare does not mandate that you use ABNs, but it does prohibit billing a Medicare beneficiary for a denied claim unless your office has a signed ABN on file. The ABN proves to Medicare that the patient understands that she might be responsible for the bill. Radiology practices use ABNs for a variety of services that Medicare may deny, such as computed tomography scans of the head and thorax, and magnetic resonance scans of the spine and brain.

Be sure each ABN you file is filled out in duplicate -- you'll need one copy for your records and one copy for the patient. Not only must you make sure the patient has a copy of the ABN; CMS doesn't consider an ABN "delivered" unless the patient understands the form and its contents. If the patient has a condition that affects her awareness, such as Alzheimer's disease (331.0), or doesn't seem to understand why you're asking her to sign the form, you should ask the patient's guardian to sign it.

"Since you are also required to have the patient and/or guardian sign a consent form for treatment and assignment of benefits, you should also ask the guardian to sign the ABN," says Sandi Scott, CPC, CORT, director of audits and training in the law department of InSight Health Corp., and an AAPC PMCC licensed instructor.

For complete instructions on using ABNs, go to www.cms.gov/manuals/pm_trans/ab02168.pdf.

View a DEXA scan ABN online: To view a sample radiology-specific advance beneficiary notice, visit http://codinginstitute.com/sample/forms/abn_sample.pdf.