Radiology Coding Alert

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 [...]