READER QUESTIONS:
Avoid This Coding-for-Coverage Mistake
Published on Tue Nov 24, 2009
Question: Our ob-gyn wants to send a patient for tumor marker testing before she does a hysteroscopy dilation and curettage (D&C) for profuse bleeding and ovarian cysts. Patient has a family history of breast cancer and some history of ovarian cancer. The patient has Medicare, but her carrier does not cover this testing. What is a possible diagnosis (other than the obvious ones) that may allow coverage? Kentucky Subscriber Answer: Red flags should be waving. You cannot fix coverage with coding -- ever. To do so qualifies as fraud. Action: Obtain informed consent from the patient and have her sign an advance beneficiary notice, which informs her that Medicare may not pay for the test. She can then decide whether to have it done or not. Medicare will pay only for a CA 125 level (86304, Immunosay for tumor antigen, quantitative; CA 125) as part of the initial pre-operative work-up for women [...]
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