Reimbursement Advisor


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Does breast exam only qualify as screening visit?

Q. I recently saw a 62-year-old Medicare patient for a breast examination only. Here is my documentation of the visit:

  • Patient is a virgin, takes no hormones, and refuses a pelvic exam and Pap smear. Blood pressure is in the normal range. Body mass index is 21. She reports no problems and has no questions.
  • Examination of breasts reveals normal skin and nipples, no masses or tenderness, and no lymph-node swelling.
  • Patient is given a slip for a routine mammogram and instructions on performing breast self-exam, and is instructed to return in 1 year, barring problems or concerns.
My question is: Does this visit qualify for billing Medicare with code G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) or should it be billed a low-level problem E/M service instead? We would use the diagnosis code V76.19 (other screening breast examination).

A. You face an interesting situation. This is a preventive service, but a diagnosis of V76.19, although accurate here, will cause code G0101, which requires that a pelvic exam have been performed, to be denied.

If you report this visit as a problem E/M service using only this diagnosis, on the other hand, you are more than likely to be denied by Medicare.

For Medicare to consider this a covered service billed as a problem E/M service, you would also have to list diagnostic codes that indicate a complaint, a history of a breast condition, or a strong family history of breast cancer. Medicare will pay for the screening mammogram, but the screening breast exam by itself may not be considered a covered service.

You have a few options:

  • Contact the Medicare carrier and explain the situation. See if they propose a coding solution that they will accept. Get their answer in writing!
  • Bill Medicare using a low-level E/M code (eg, 99212, problem focused exam with straightforward medical decision making) linked to the diagnosis code V76.19. If you choose this option, have the patient sign a waiver that she is responsible for payment should Medicare deny the service. Add the modifier –GA (waiver of liability statement on file) to the problem E/M code. This will allow you to collect payment from the patient.
  • Submit the unlisted code or preventive services 99429 because you performed an exam—although not one that meets the criteria of age-specific preventive codes. This code is never reimbursed by Medicare, but once you get a denial, you either can collect from the patient or are able to submit the charge to any secondary insurance she might have. A modifier –GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit) would also need to be added to the preventive medicine code.

Fern testing: CLIA-waived but payer might not cover

Q. What is the correct code for fern testing? The codes recommended to us are 89060 or 87210, not Q0114, which isn’t recognized by some of our payers. Can you give us advice?

A. The fern test should never be coded 87210 because that code does not represent how the test is performed. (Fern testing is simply applying vaginal fluid to a slide, which is left to dry, and observing whether a ferning develops when the residue is viewed under a microscope.) The test is performed by the provider, not the laboratory; as such, Q0114 is the correct code.

Code 87210, in addition to requiring addition of saline or potassium chloride, is not a CLIA-waived test. You would not be able to bill for it unless you have an advanced lab certificate.

Code 89060 is assigned when looking for crystals in synovial fluid. It is also not a CLIA-waived or physician-performed microscopy test, so billing using this code would require an advanced lab certificate as well.

The advent of the national code set has meant that your payers are required to recognize all codes, although they can determine whether to cover a service or not. It may be that this test isn’t covered by your payer, rather than the code not being recognized as correct.

Two voiding studies: Bill together but specify parts

Q. Can both the 51795 voiding pressure study and 51797 intra-abdominal voiding pressure study be billed together? When I checked the bundling software, it lists these codes as mutually exclusive, with 51795 having an indicator of “1” and 51797 a “9.” If the codes can be billed together, should I use a modifier -59 (distinct service)?


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