Reimbursement FAQ’s
iCAD works closely with reimbursement specialists to track the clinical policies, medical necessity guidelines, coding edits and reimbursement rules maintained by the CMS and insurance industry. Reimbursement rates and guidelines vary by medical plan/policy, plan type, state, zip code, service location and a myriad of complex clinical and financial rules for each insurance provider and managed care organization. In addressing frequently asked reimbursement questions we have provided information on Coding and Billing Information including Basic Coverage Rules, Billing Codes, and Guidelines on reimbursement.
Under §4601, the Benefits Improvement and Protection Act (BIPA) of 2000 amended §1848(j)(3) of the Social Act Security Act to include screening mammography as a physician service for which payment is made under the Medicare Physician Fee Schedule (MPFS). The previous, statutory payment limitation for screening mammography no longer applies for claims with dates of service on or after January 1, 2002. Note that Medicare payment amounts and coverage policies for specific procedures will vary by geographic location. To confirm reimbursement rates, you should consult your local carrier or fiscal intermediary for specific codes.
Mammography Reimbursement by Other Payers
Reimbursement policies of private payers will vary, depending on a variety of factors including location, payment arrangements, patient volume, etc. While some private payers may rely on Medicare reimbursement amounts as the basis for their reimbursement policies, many others may consider alternative information. Similarly, Medicaid program reimbursement rates and methods will vary across and within states.
Coding/Billing Information
Basic Coverage Rules
The law, Mammography Quality Standards Act (MQSA), requires the Secretary to ensure that all facilities that provide mammography services meet national quality standards. Effective October 1, 1994, all facilities providing screening and diagnostic mammography services (except VA) must have a certificate issued by the Food and Drug Administration (FDA) in order to be reimbursed by Medicare.
The Medicare law and regulations provide for coverage of screening mammograms for women without signs or symptoms of breast disease for the purpose of early detection of breast cancer, including a physician's interpretation of the results of the procedure.
Guidelines
Screening Mammography
Coverage typically applies as follows:
l Under age 35 = No payment is allowed for screening
l Age 35 to 39 = (Baseline) Pay for only one screening mammography performed on a woman between her 35th and 40th birthday
l Over age 39 (i.e.: 40 and over) = Annual (11 full months have elapsed following the month of last screening).
l Part B deductible is waived per BBA however co-insurance applies.
A doctor's prescription or referral is not necessary for screening mammograms to be covered.
Diagnostic Mammography
A diagnostic mammogram is a covered radiological procedure that is 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.
Same Day Coverage
Diagnostic mammography and screening mammography can both be paid when performed on the same day when provided to the same beneficiary. New modifier GG should be added to the diagnostic procedure code to identify that both a screening mammogram and a diagnostic mammogram were performed on the same patient on the same day. Both the screening mammogram and the diagnostic mammogram should be billed on the same claim. It will no longer be necessary for the treating physician to submit an order for additional film images.
Changes in Mammography HCPCS codes
As of January 1, 2007 new CPT codes have been assigned to mammography services for screening and diagnostic services. CPT code descriptors for the services will remain unchanged. The following chart provides guidance for billing of CAD add-on codes. It reflects appropriate coding combinations that may be billed:
2007 Current Procedural Terminology (CPT) Mammography Codes
| Procedure | CAD Code* (Effective 2007) |
Primary Code (Effective 2007) |
|---|---|---|
Screening Mammography - Film Two view film study each breast |
77052 (Formerly 76083) |
77057 (Formerly 76092) |
| Screening Mammography - Digital Bilateral, all views | 77052 (Formerly 76083) |
G0202 |
Diagnostic Mammography - Film |
77051 (Formerly 76082) |
77055 – (Unilateral) (Formerly 76090) 77056 – (Bilateral) (Formerly 76091) |
Diagnostic Mammography - Digital |
77051 (Formerly 76082) |
G0204 – (Unilateral) G0206 – (Bilateral) |
*CAD Codes are designated as “add-on” codes and MUST be billed in conjunction with the primary code. |
Modifier “-GG”: Performance and payment of a screening mammography and diagnostic mammography on same patient same day. This is billed with the Diagnostic Mammography code to show the test changed from a screening test to a diagnostic test. Contractors will pay both the screening and diagnostic mammography exams. This applies to claims with dates of service on or after January 1, 2002.
© 2006 iCAD, Inc. All rights reserved.
