Home Forums Discussions General Discussion Tricky Medicare Coding/Gender Situation

I'm hoping someone has some thoughts/suggestions on this issue. This has to be my most complicated coding issue I've ever had.

I saw a new patient 68 y/o, on Medicare, and was coming for Wellness Exam. On further discussion with patient, she has been having some chest discomfort off and on, sometimes with and sometimes without activity for the last several months but has been under much more stress, so uncertain if cardiac source or anxiety related. The patient is now female (underwent gender reassignment surgery in the past -- testicles removed and vaginal construction) and Medicare card has sex listed as female.

In addition to her exam, she had EKG, Pneumovax, and rectal/prostate exam. In addition, referral placed for screening colonoscopy, bone density, AAA screen, and cardiac stress testing.

This is what I coded:

G0439 (v70.0) for New Wellness Exam
99204 -25 for separate E/M service for the chest pain
93000 for EKG
G0009/90732 for Pneumovax administration/vaccine
G0102 for prostate exam

My concerns are:

#1. Medicare paying G0439 with 99204 -25
#2. Medicare paying for G0102 since Medicare card states patient is female
#3. Medicare paying for AAA screening since card states female
#4. Medicare paying for bone density screening (I presume they should since Medicare card states female)

Thanks for any help/suggestions on this coding challenge!

Wow, now that is complex. That must have taken a long time. I, too, have wondered about doing a level 4 with a wellness, but I think it works with the -25 modifier. I try to keep these separate for not just billing questions, but also headache factor. I would be interested in hearing more about this case, and a separate coding forum would be really helpful as I do all my own.

Boondoc -- I'll keep you posted on what happens when this is submitted. The lab that I share space with also is questioning if the PSA will be covered by Medicare since the insurance card is listed as female as well.

John,

I have a similiar patient (yes, in Creston) who was on 3rd party insurance, who underwent gender reassignment surgery, and the prostate exam was paid for. No denial, just paid for.

Thanks for letting me know Tom. I figured someone else had to encounter this situation before as well. Enjoy the heat up there!