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Mammography - Medicare Reimbursement
Medicare Reimbursement for
Mammography Services in Calendar Year 2005
Effective January 1, 2005, The Centers for Medicare and Medicaid Services (CMS) updated the payment amounts for both film-based and digital mammography procedures. CMS provides for additional reimbursement of computer-aided detection (CAD) when used with digital or film-based mammography. These payment rates are also updated effective January 1, 2005. Below is a report of Medicare reimbursement for mammography services for CY 2005.
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Mammography
Coding for Mammography
Diagnostic mammography is a radiologic 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. Screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer.i
Medicare's reimbursement system for mammography relies on Current Procedural Terminology (CPT) codesii to consistently identify some mammography services provided to Medicare patients. The CPT codes relating to mammography are as follows:
| CPT 76090 |
Mammography; unilateral |
| CPT 76091 |
bilateral |
| CPT 76092 |
Screening mammography, bilateral (two view film study of each breast) |
In addition, Medicare utilizes Healthcare Common Procedure Coding System (HCPCS) codes to reflect the use of certain advanced new mammography technologies including digital mammography and computer-aided detection (CAD) for diagnostic mammography. These codes are as follows:
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| HCPCS G0202 |
Screening mammography producing direct digital image, bilateral, all views |
| HCPCS G0204 |
Diagnostic mammography, producing direct digital image, bilateral, all views |
| HCPCS G0206 |
Diagnostic mammography, producing direct digital image, unilateral, all views |
Medicare also reimburses for computer aided detection (CAD) as a separate, add-on payment when used with either film-based or digital mammography. The table below shows the CPT codes to be used with the appropriate type of procedure:
| CPT 76082 |
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) |
| CPT 76083 |
Screening mammography (List separately in addition to code for primary procedure) |
Effective January 1, 2004, CPT code 76082 can be reported in conjunction with the primary service mammography CPT codes 76090 or 76091, as well as HCPCS codes G0204 or G0206. CPT code 76083 can be reported in conjunction with the primary service mammography code, CPT 76092 or HCPCS G0202. (Refer to the Medicare Claims Processing Manual at: http://www.cms.hhs.gov/manuals/104_claims/clm104c18.pdf and scroll to p. 48.)
Medicare will reimburse providers for medically necessary screening and diagnostic mammography procedures that are performed on the same patient on the same day. The modifier –GG “Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day,” must be attached to the appropriate diagnostic mammography procedure code. In a scenario where a patient has a screening mammogram performed on one day and returns on another day for the additional diagnostic mammogram, both the screening mammogram and diagnostic mammogram services should be coded separately without the use of modifier –GG. This policy applies to both film and digital mammography procedures. (Refer to the Medicare Claims Processing Manual at: http://www.cms.hhs.gov/manuals/104_claims/clm104c18.pdf and scroll to p. 44.)
Medicare Coverage Policy and Payment Amounts
Medicare provides coverage for both diagnostic and screening mammography; guidelines control the frequency of coverage for screening mammography.iii Both diagnostic and screening mammographies include a physician's interpretation of the results of the procedure.
Medicare reimbursement for mammography services is comprised of a professional component, the amount paid for the physician's interpretation of the results of the examination, and a technical component, the amount paid for all other services (including technician and equipment costs). When combined and paid to the same physician, this is the total or global reimbursement. For computer-aided detection (CAD), Medicare reimburses a separate, add-on payment, which is also comprised of professional and technical components.
In late 2003, Congress passed the Medicare Prescription Drug, Improvement and Modernization Act of 2003, which contains a provision relating to Medicare reimbursement for mammography services. Specifically, both diagnostic and screening mammography services are paid under the Medicare Physician Fee Schedule, regardless of the site of service, effective January 1, 2005iv.
Refer to Table 1 for a summary of Medicare payment amounts in 2005 for both screening and diagnostic mammography services, for freestanding diagnostic imaging centers and physicians’ offices, as well as hospital outpatient departments. 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.
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Table 1: 2005 Medicare Reimbursement For Mammography Services
TABLE 1: 2005 MEDICARE REIMBURSEMENT FOR MAMMOGRAPHY SERVICES
Provided in Freestanding Diagnostic Imaging Centers, Physicians’ Offices or Hospital Outpatient Departmentsv
Reflects National Average Rates, Which Are Adjusted For Locality |
| Procedure |
Medicare Reimbursement Component |
PLAIN FILM
National Medicare Payment Amount for 2005 |
DIGITAL TECHNOLOGY
National Medicare Payment Amount for 2005 |
CAD TECHNOLOGYvi
National Medicare Payment Amount for 2005
(add-on to film or digital procedure) |
| Unilateral Diagnostic Mammographyvii |
Technical Component |
$42.07 |
$78.83 |
$16.30 |
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Professional Component |
$36.38 |
$36.38 |
$3.41 |
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Total Payment Amount |
$78.45 |
$115.21 |
$19.71 |
| Bilateral Diagnostic Mammographyviii |
Technical Component |
$52.30 |
$97.40 |
$16.30 |
| Professional Component |
$45.10 |
$45.10 |
$3.41 |
| Total Payment Amount |
$97.40 |
$142.50 |
$19.71 |
| Screening Mammographyix |
Technical Component |
$49.27 |
$98.91 |
$16.30 |
| Professional Component |
$36.38 |
$36.38 |
$3.41 |
| Total Payment Amount |
$85.65 |
$135.29 |
$19.71 |
Notes:
i. 42 CFR §410.34(a).
ii. CPT codes and descriptions only are copyright© 2004 American Medical Association. All rights reserved. No fee schedules are included in CPT. The American Medical Association assumes no liability for data contained or not contained herein.
iii. 42 CFR §410.34(a)(2).
iv. Prior to 2005, Medicare reimbursed providers for diagnostic mammography services as well as CAD for diagnostic mammography differently depending on where they are performed. Diagnostic mammography procedures performed in a physician office or a freestanding independent diagnostic testing facility were reimbursed on the basis of the Medicare Physician Fee Schedule. In a hospital outpatient department, the technical component of a diagnostic mammography service was reimbursed under an ambulatory payment classification (APC) under the hospital outpatient department prospective payment system (OPPS). However, the professional component of a diagnostic mammogram performed in a hospital outpatient department was reimbursed under the Medicare Physician Fee Schedule. Screening mammography services, as well as CAD for screening mammography services, were reimbursed under the Medicare Physician Fee Schedule, regardless of the site of service. (Refer to §104 Benefits Improvement and Protection Act (BIPA) 2000.)
v. Third party reimbursement amounts and coverage policies for specific procedures will vary by payer and by locality. Information presented above is representative of 2005 Medicare professional and technical payment amounts for participating facilities, with relative value units (RVUs) as published in the Federal Register, vol. 69, no. 219, November 15, 2004. Actual reimbursement amounts for each procedure listed will vary depending on payer and procedure mix, as well as facility location. Amounts do not necessarily reflect any subsequent changes in payment since publication.
vi. For add-on to diagnostic, use CPT code 76082, 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).
For add-on to screening, use CPT code 76083, 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).
vii. For plain film, CPT code 76090, Mammography; unilateral. For digital technology, code G0206, Diagnostic mammography, direct digital image, unilateral, all views.
viii. For plain film, CPT code 76091, Mammography, bilateral. For digital technology, code G0204, Diagnostic mammography, direct digital image, bilateral, all views.
ix. For plain film, CPT code 76092, Screening mammography, bilateral (two view film study of each breast). For digital technology, code G0202, Screening mammography producing direct digital image, bilateral, all views.
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