Accurate diagnosis coding is crucial for healthcare providers, especially when it comes to billing for diagnostic mammograms. This guide provides essential information on diagnosis codes for diagnostic mammograms, ensuring compliance and proper reimbursement, particularly under Medicare guidelines. Understanding these guidelines is vital for healthcare practices to maintain financial stability and provide uninterrupted patient care.
General Guidelines for Diagnostic Mammogram Claims
When submitting claims for diagnostic mammograms, whether to Part A or Part B Medicare Administrative Contractors (MACs), several general guidelines must be followed. Procedure codes related to mammography are often subject to National Correct Coding Initiative (NCCI) edits and Outpatient Prospective Payment System (OPPS) packaging edits. Therefore, it’s imperative to consult NCCI and OPPS requirements before submitting any claims to Medicare.
For services that necessitate a referring or ordering physician, the claim must include the name and National Provider Identifier (NPI) of the respective physician. Critically, Medicare claims lacking a valid ICD-10-CM diagnosis code will be deemed incomplete and returned to the provider. The diagnosis code(s) reported must accurately reflect the patient’s condition that necessitated the diagnostic service. In cases of diagnostic tests, if the test result is known, it should be reported. If the result is not available, the symptoms that prompted the diagnostic mammogram should be documented instead. This ensures that the medical necessity of the procedure is clearly justified.
Advance Beneficiary Notice (ABN) and Modifier Usage
In situations where a diagnostic mammogram service might not be covered by Medicare, an Advance Beneficiary Notice of Non-coverage (ABN) may be necessary. This is applicable whether the potential non-coverage is due to medical necessity issues or other reasons. For detailed instructions regarding ABNs, refer to the CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30.
For services rendered on or after April 1, 2010, non-covered services should be billed with specific modifiers to indicate the circumstances of the non-coverage. The appropriate modifiers are -GA, -GX, -GY, or -GZ.
-GA Modifier: Waiver of Liability Statement Issued as Required by Payer Policy
The -GA modifier is used when providers anticipate that Medicare might deny a diagnostic mammogram service as not reasonable and necessary, and they have obtained a properly signed ABN from the beneficiary. This modifier is applicable only when services are expected to be denied under the ‘reasonable and necessary’ provisions, as outlined in sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. When claims are submitted to Part A MAC systems with the -GA modifier, they will be automatically denied. The beneficiary should sign an ABN, Form CMS-R-131, acknowledging their responsibility for payment in case of denial. The -GA modifier can also be used on assigned claims if a patient refuses to sign the ABN, provided the refusal is properly witnessed. For Part A MAC claims using the -GA modifier, occurrence code 32 and the date of the ABN are required.
-GX Modifier: Notice of Liability Issued, Voluntary Under Payer Policy
The -GX modifier is appropriate when an ABN has been signed by the beneficiary, and a denial is anticipated for reasons other than medical necessity. These reasons can include statutory exclusions of coverage or technical issues. While an ABN is not mandatory for these types of denials, using the -GX modifier for non-covered services will result in automatic denial of the claim.
-GZ Modifier: Item or Service Expected to Be Denied as Not Reasonable and Necessary
The -GZ modifier is used when providers expect Medicare to deny a diagnostic mammogram service as not reasonable and necessary, and an ABN has not been signed by the beneficiary.
-GY Modifier: Statutorily Excluded Service
If a service is statutorily non-covered or lacks a benefit category under Medicare, the appropriate CPT/HCPCS code should be submitted with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply to beneficiaries. Services billed with the -GY modifier will also be automatically denied.
Essential Documentation Requirements
Comprehensive and accurate documentation is paramount for all diagnostic mammogram services billed to Medicare. The patient’s medical record must include, but is not limited to:
- Assessment by the Ordering Provider: Documentation of the ordering provider’s assessment concerning the patient’s complaint during the visit.
- Relevant Medical History: Pertinent medical history related to the patient’s current condition.
- Results of Pertinent Tests/Procedures: Results from any relevant prior tests or procedures.
- Signed and Dated Records: A signed and dated office visit record or operative report. It is crucial to note that all services ordered or rendered to Medicare beneficiaries must be signed to be considered valid.
For diagnostic mammograms, breast sonograms, breast MRIs, or ductograms, a clear clinical indication must be documented in the medical record and in the referral order. A written referral is required for a diagnostic mammogram unless it originates from a screening mammogram. The medical record should contain a formal written report detailing all views completed, the reason for the test, a description of the procedure, the interpretation and results, and the name of the physician who will receive the report.
If a diagnostic mammogram evolves from a screening mammogram due to abnormal findings, the specific abnormality must be clearly documented in the patient’s record. The GG modifier must be included on the claim line with the CPT procedure code for the diagnostic mammogram in such cases. All documentation must be readily available to Medicare upon request. Providers should also refer to the Indications and Limitations section of the Local Coverage Determination (LCD) for further details.
Other Important Considerations
For Part A MAC claims, this coverage determination is also applicable in states outside the primary geographic jurisdiction for facilities that have nominated CGS Services to process their claims. Bill type codes are relevant only to providers billing Part A MAC, and not to physicians or other professionals billing Part B MAC.
Limitations of liability and refund requirements are applicable when denials are anticipated, whether due to medical necessity or other coverage reasons. Providers must inform beneficiaries in writing prior to service delivery if they are aware that a test, item, or procedure might not be covered by Medicare. However, these limitations and refund requirements do not apply to services statutorily excluded, lacking a Medicare benefit category, or performed for screening purposes.
By adhering to these guidelines regarding diagnosis codes and billing practices for diagnostic mammograms, healthcare providers can ensure accurate claim submissions, reduce denials, and maintain compliance with Medicare requirements.
