Medicare Part B. Mammograms - Updated Billing Guide for Screening and Diagnostic Tests

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1 Mammograms - Updated Billing Guide for Screening and Diagnostic Tests This article from Medicare B News Issue 223 dated October 21, 2005 is being updated and reprinted to ensure that the Noridian Administrative Services provider and supplier community has access to recent publications that contain the most current, accurate and effective information available. This article provides all the current billing information for screening and diagnostic mammograms. The information in this article replaces previous articles on this topic. Mammograms should be billed based on Transmittal 1070, Change Request 5327 dated September 29, 2006 and in accordance to the billing and payment instructions found in the Internet Only Manual (IOM) Publication , Medicare Claims Processing Manual, Chapter 18, Section 20. Effective for dates of service on or after January 1, 2007, CPT was replaced with for screening mammograms per Change Request (CR) Effective for dates of service on or after January 1, 2007, CPT code was deleted and replaced with for diagnostic mammograms per CR There were several other changes effective January 1, 2007 that include: replaced with 77055, replaced with 77056, and replaced with (see CR 5327.) Screening Mammograms Screening mammograms are radiological procedures furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and include a physician's interpretation of the results. The service must be,

2 at a minimum, a two-view exposure (that is, a cranio-caudal and a medial lateral oblique view) of each breast. Coverage The following coverage guidelines are to be applied to all screening mammograms: 1. A doctor's prescription or referral is not necessary for the procedure to be covered. 2. Medicare pays for routine screening mammograms annually for women over For women ages 35-39, a baseline mammogram is allowed once during this period of time. No payment may be made for a woman under age Deductible is waived but the 20% coinsurance applies. 5. All mammography tests are paid under the Medicare Physician Fee Schedule (MPFS). Note: The allowed charge is the lower of the actual charge or the MPFS amount. The Medicare payment for the service is 80% of the allowed charge, with a coinsurance amount of 20% of the lower of the actual charge or the MPFS amount. Non-participation reduction and the limiting charge provisions apply to all mammography tests (including screening mammography) as with other MPFS services. To determine the benefit frequency: Count the months between the mammography exams, beginning the month after the date of the examination. For example, if Mrs. Smith received a screening mammography examination on January 10, 2007; begin counting the next month (February 2007) until eleven full months have elapsed. Payment can then be made for another screening mammography for any date in January Only one screening mammogram, either or G0202, may be billed in a calendar year. Medicare will only cover one type of mammogram per year, film or digital, not both types.

3 Codes Screening mammogram, bilateral (two view film study of each breast). G0202* Screening mammography, producing direct digital image, bilateral, all views (Effective for dates of service on/after April 1, 2001). (Please note that CPT code was replaced with on January 1, 2007.) Code Computer aided Detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images, screening mammography. (List separately in addition to code for primary procedure). Effective January 1, must be billed in conjunction with or G0202 or the service will be denied. When 77052, billed in conjunction with a screening mammography, fails the age or frequency edit, both services will be rejected. Diagnosis Coding The primary diagnosis of V76.11 (for dates of service on/after July 1, 2005) or V76.12 must be used for screening mammograms. Unilateral Screening Mammogram For those rare occasions when performing a unilateral screening mammogram, since is inherently bilateral, bill (and 77051, if appropriate) or G0202 with a modifier 52, reduced service, along with an explanation in Item 19 on the CMS 1500 claim form or the electronic equivalent. The appropriate reduced charge for a unilateral mammogram should also be reflected on the claim based on the provider's usual charge for a bilateral

4 mammogram. Medicare will reimburse the lower of the actual billed amount or the fee schedule amount. Mammography Certification Required for Screening Mammograms Screening mammography services are reimbursed by Medicare only if furnished by suppliers certified by the Food and Drug Administration (FDA), per Section 354 of the Public Health Service Act. The six digit FDA assigned certification number must be entered in Item 32 on the CMS 1500 claim form or the electronic equivalent. The FDA furnishes data to CMS on a weekly basis, which specify the certification of facilities under the Mammography Quality Standards Act (MQSA). This data is contained in a MQSA file. The FDA provides CMS with a listing of all providers that have been issued certificates to perform mammography services and CMS notifies contractors accordingly. Diagnostic Mammograms A diagnostic mammogram, as defined in Section of the Code of Federal Regulation (CFR), is a radiological procedure 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, including a physician's interpretation of the results. Coverage The following coverage guidelines are to be applied to all diagnostic mammograms: 1. Diagnostic mammograms must be ordered by a physician or qualified nonphysician practitioner and are covered as often as is medically necessary. 2. The patient is responsible for the deductible and coinsurance. 3. Medicare Part B covers diagnostic mammograms for symptoms, which include breast discharge, a mass, knot, a lump that can be felt or pain in the breast area. Code Mammography; unilateral (Diagnostic)

5 77056 Mammography; bilateral (Diagnostic) G0204 G0206 Diagnostic mammography, producing direct digital image, bilateral, all views (effective for dates of service on/after April 1, 2001) Diagnostic mammography, producing direct digital image, unilateral, all views (effective for dates of service on/after April 1, 2001) Only one type of diagnostic mammogram will be covered, either film or digital. Therefore, do not submit claims with codes or (film) and G0204 or G0206 (digital). Code Computer-aided Detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images, diagnostic mammography. (List separately in addition to code for primary procedure). Effective January 1, 2004, must be billed in conjunction with a regular diagnostic mammography code or the service will be denied. Effective January 1, 2007, must be billed in conjunction with a regular diagnostic mammography code or the service will be denied. The following ICD-9-CM codes are covered for diagnostic mammography ICD-9-CM V10.3 Personal history of malignant neoplasm-breast V15.89 Other specified personal history presenting hazards to health Malignant neoplasm of female breast Malignant neoplasm of male breast Secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb

6 197.0 Secondary malignant neoplasm, lung Secondary malignant neoplasm, mediastinum Secondary malignant neoplasm, pleura Secondary malignant neoplasm, other respiratory organs Secondary malignant neoplasm of liver, specified as secondary Secondary malignant neoplasm of other specified sites (skin of breast) Secondary malignant neoplasm of brain and spinal cord Secondary malignant neoplasm of bone and bone marrow Secondary malignant neoplasm of breast Disseminated malignant neoplasm without specification of site Other malignant neoplasm without specification of site 217 Benign neoplasm of breast Carcinoma in situ of breast Neoplasm of uncertain behavior of breast Neoplasm's of unspecified nature of breast Benign mammary dysplasias Other disorders of breast Signs and symptoms in breast Other specified disorders of breast Unspecified breast disorder Nonspecific abnormal findings on radiological and other examination of body structure, breast FDA Certification Requirements Screening and diagnostic mammograms (film and digital) are subject to Food and Drug Administration (FDA) certification. However, Computer Aided Detection (CAD)

7 equipment does not required FDA certification. Mammography utilizes a direct x-ray of the breast. By contract, the CAD process uses laser beam to scan the mammography film from a film (analog) mammography, converts it into digital data for the computer and analyzes the video display for areas suspicious for cancer. The CAD process used with digital mammography analyzes the data from the mammography on a video display for suspicious areas. The patient is not required to be present for the CAD process. Screening and Diagnostic Mammogram Performed on Same Day Effective January 1, 2002, when a radiologist interpretation of screening mammography results in the performance of a diagnostic mammography on the same day for the same beneficiary, payment may be made for both tests. The modifier GG should be used with the diagnostic mammogram code to show that the screening test became a diagnostic test. Screening or Diagnostic Mammogram with Past History of Breast Cancer Recently, questions have been raised about yearly routine mammograms regarding whether a routine mammogram could be considered screening, if the patient has a past history of breast cancer. The CMS response to this question is as follows: "It was intended for the personal history of breast cancer to fit under either diagnostic or screening. It is the choice of the patient's attending physician to decide whether the patient should have a screening or diagnostic mammogram. One school of thought was that mammograms should always be diagnostic. However, there was concern that since the deductible is waived for the yearly mammography screening, it would be unfair to women who were symptom free to not have the opportunity for a screening, even if they have had breast cancer. To summarize, the patient and their doctor have a choice. If the patient and doctor want the mammogram to be a diagnostic, it can be billed as such. If it is to be a screening mammography, then that is how it should be billed, even with a personal history of breast cancer." Mammograms for Women with Breast Implants Physicians have asked whether mammograms taken for women with breast implants are considered screening or diagnostic. Women with implants require at least one

8 additional X-ray view to accurately assess all the breast tissue for potential abnormalities. Although many radiologists have given the opinion that breasts with implants are inherently abnormal, current Federal regulations do not concur. Section 42 CFR (a) of the current Medicare regulations defines the terms diagnostic and screening mammography for payment purposes. Section (a)(1) defines the term "diagnostic mammography" to mean "a radiological procedure 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 breast disease, and includes a physician's interpretation of the results of the procedure." Section (a)(2) defines the term "screening mammography" to mean, "a radiological procedure furnished to a woman without signs or symptoms of breast disease, and includes a physician's interpretation of the results of the procedure." Therefore, mammograms in patients with implants with history of prior breast cancer, or with any current signs or symptoms of breast disease (scarring, nodules, fibrocystic changes, pain, discharge, etc.) could be considered diagnostic exams, but patients without signs or symptoms of breast disease can only be reimbursed as screening tests. Medicare allows a radiologist to order additional mammography views when a screening mammography shows a potential problem. Implants producing difficulties with density or poor visibility may constitute a potential problem and thus qualify. Appealing Mammogram Claims When appealing screening or diagnostic mammograms, you may not change a diagnostic to a screening or a screening to a diagnostic unless you have documentation (office notes and mammogram report) indicating the mammogram was, in fact, ordered that way. Applies to the states of: AK, AZ, HI, ND, NV, OR, SD, WA & WY. Effective for dates of service on or after January 1, 2007 Sources: Program Memorandum 1814, CR 2632; Transmittal 1070, Change Request 5327 dated September 29, 2006; IOM Publication , Medicare Claims Processing Manual, Chapter 18, Section 20 Mammography Services (Screening and Diagnostic)

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