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Diagnostic Mammogram for Male Patients - Getting denials

Hattiesburg Posted Wed 28th of February, 2018 15:00:55 PM
I have received 4 denials on male patients who had a diagnostic, bilateral mammogram, with tomo. We billed 77066 and G0279. The denial reason code is CO7 (patient gender is inconsistent with procedure code). The rep at Medicare is telling us we need to use a modifier because the patient is male. I can't find any modifier to reflect this. Do you know of any modifier or diagnosis code they want to indicate this is a male patient? All four exams are for bilateral, diagnostic mammograms due to mastodynia and/or hypertrophy of breast. All dates of service are in 2018. I have already requested they check their edits, since this is a new code for 2018, and they insist we need to add a modifier. Please advise and thank you in advance for your assistance.
SuperCoder Answered Thu 01st of March, 2018 03:40:51 AM

Hi,

As per the cms guideline a diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy proven benign breast disease, and includes a physician’s interpretation of the results of the procedure. A diagnostic mammography is a covered service if it is ordered by a doctor of medicine or osteopathy as defined in §1861 (r) (1) of the Act. 

So, it should be covered because it states diagnostic mammogram on man or women. Screening mammogram are not covered by medicare for males. 

There is no particular modifier that representss the service on males. You need to appeal to medicare for the denial. 

https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/20059_13/l20059l20060l20061l20062_rad005_cbg_040111.pdf

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