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Reimburesment

Reimbursement is a key factor to the profitable use of Computer-Aided Detection (CAD) systems within the healthcare community. For your convenience, assorted information on market trends, rates, billing codes, and guidelines can be found below.

Market Trends

iCAD works closely with reimbursement specialist HealthCare IQ to track the clinical policies, medical necessity guidelines, coding edits and the reimbursement rules maintained by the insurance industry. HealthCare IQ recently conducted a trend analysis of CAD reimbursements, denial rates and clinical policies to investigate its acceptance in the United States. Based on the following trend findings, HealthCare IQ concluded that a significant change in the way CAD is being adjudicated by the insurance industry occurred in 2005:

A significant drop in the number of claims being denied for medical necessity reasons
CAD reimbursement rates are increasing
HIPAA has reduced the number of coding errors made by insurance companies

Rates

CAD reimbursement rates are increasing. The average 2005 reimbursement rate for screening mammography CAD is $19.80, consisting of $16.31 (technical component reimbursed to the facility) plus $3.49 (professional component reimbursed to the physician's group). The average 2005 reimbursement rate for diagnostic mammography CAD in a hospital setting is $8.34.

Medicare: Effective January 1, 2005 all Medicare Payments are paid under the Medicare Physician Fee Schedule (MPFS).

Commercial Insurance: Reimbursement rates very by state, zip code, plan type, medical policy, place of service, and a myriad of complex clinical and financial rules for each insurance company and managed care organization, to obtain specific reimbursement information contact HealthCare IQ at +1 203 250 8700.

Billing Codes

CAD codes are designated as "add-on" codes and can not be billed alone. As such, they must be billed with a primary mammography code as follows:

Procedure	CAD Code	Primary Code
Diagnostic Mammography	76082	76090 (Unilateral) 76091 (Bilateral)
Screening Mammography	76083	76092

Guidelines: Diagnostic Mammography and CAD

A diagnostic mammogram and CAD are covered radiological procedures that are furnished to a man or woman with signs or symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and it includes a physician's interpretation of the results of the procedure. Unlike the screening mammogram, the diagnostic procedure does require a doctor's prescription or referral in order for coverage to be available.

A diagnostic mammogram (film or digital) are generally considered medically necessary under any of the following conditions:

The patient has a personal history of breast cancer.
The patient has distinct signs and symptoms for which a mammogram is indicated, such as but not limited to:

breast mass or nodes
painful or tender breasts
change in the color, surface, size and/or shape of the breast, nipple or skin
nipple discharge

Based on the patient's history and other significant factors, a mammogram is appropriate. Conditions such as, but not limited to, those listed below warrant the medical necessity for mammograms:

metastases or nodes in areas of the body other than the breast but the primary site is unknown
history or presence of endometrial cancer
previous suspicious lesions or masses of the breast
where evaluation by palpation is difficult because of large fatty breasts, augmented breasts, or implanted breasts

Guidelines: Screening Mammography and CAD

Annual screening mammograms and CAD are a covered benefit. Mammograms for the routine screening of asymptomatic women, whether or not family members have had breast cancer, or whether or not physician recommended, are considered screening and CAD.

Payment is generally made for one routine screening mammogram and CAD procedure per calendar year for asymptomatic women forty years of age or older. Additionally, physician recommended mammograms are covered for women under age forty regardless of the reason performed. Self-referred screening mammograms and CAD for women under age 40 are generally not covered. Coverage for screening mammography is determined according to individual or group customer benefits.