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Ob-Gyn Coding Alert

Reader Question:

Medicare Likely Wont Pay for Male Mammograms

Question: An ob-gyn ordered a screening mammogram for a male Medicare patient with a family history of breast cancer. What ICD-9 code should I report to prove medical necessity for this service? Puerto Rico Subscriber Answer: 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 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 35-39." The carriers that do not maintain specific exclusions for males usually state in their policies that the benefit is available for women. In addition, many regional LMRPs clearly state that they will deny any screening mammograms for male patients.

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. The ABN informs Medicare beneficiaries that Medicare may not cover a particular service or procedure, and it notifies the patient of his responsibility to pay if Medicare does not. The ABN must clearly identify the service that you render and state the reason that Medicare may deny it.

Your practice should document a meticulous patient history because ob-gyns normally refer male patients for mammography only if they have signs or symptoms, such as a mass, nipple discharge, pain or swelling. In such cases, you should report the appropriate ICD-9 codes for the signs or symptoms, along with the appropriate CPT code for either unilateral or bilateral diagnostic mammography.  

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