Screening Mammography Show Update: Medicare now requires an add-on code when you furnish a mammography using 3-D mammography in conjunction with a 2-D digital mammography, effective January 1, 2015. HCPCS/CPT Codes 77052 – Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation; screening mammography (List separately in addition to code for primary procedure) 77063 – Screening digital breast tomosynthesis; bilateral (List separately in addition to code for primary procedure) (Use this as an add-on code to G0202 when tomosynthesis is used in addition to 2-D mammography) – average fee payment – $50 – $60 use modifier –GG to show a screening mammogram turned into a diagnostic mammogram.
A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection breast cancer,and includes a physician’s interpretation of the results of the procedure. A screening mammogram does not require a physician’s referral, however, detection of a radiographic abnormality, may prompt the interpreting radiologist to order additional views on the same day. When this is the case, the mammography is no longer considered to be a screening exam and should be reported as a diagnostic mammogram. Radiologists who order additional tests must refer back to the treating physician or qualified non-physician practitioner for his/her UPIN and report back to the treating physician the condition of the patient. No separate reimbursement will be made for additional views. The cost for additional views is included in the cost of the diagnostic mammography service. Screening mammogram(s) (digital and non-digital) for the following indications are allowed: Asymptomatic women ages 40 and older are eligible for a screening mammography (digital and non-digital) performed after at least 11 months have passed following the month in which the last screening mammography was performed. Women between the ages of 35 and 39 are eligible to receive one baseline screening mammogram. Women with breast implants are eligible for screening mammography when the screening mammogram is performed within the aforementioned age and frequency limitations. Services will only be allowed if supplied by certified suppliers or FDA-certified mammography centers. Diagnostic Mammography A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician’s interpretation of the results of the procedure. Diagnostic mammogram(s) are allowed for the following indications: -the patient is under the care of the referring/ordering physician or qualified non-physician practitioner; Diagnostic breast evaluation may be indicated in cases of a personal history of malignancy and in cases of benign biopsy-proven breast disease. These diagnoses should not, however, routinely warrant a diagnostic mammography. A breast implant does not necessarily imply that a mammogram is diagnostic in nature. Although additional views may be needed, these additional views do not necessarily constitute a diagnostic mammogram, unless there are specific findings that require investigation. Medicare Part B covers diagnostic mammography services if they are furnished by a facility that meets the certification requirements of section 354 of the Public Health Service Act (PHS Act), as implemented by 21 CFR part 900, subpart B. As of October 1, 1994, the Mammography Quality Standards Act requires that all mammography centers that bill Medicare be certified by the Food and Drug Administration (FDA). Only FDA-certified mammography centers will be reimbursed. A physician (or qualified non-physician practitioner) referral is required for diagnostic mammography. The patient must be under the care of the physician (or qualified non-physician practitioner) who orders the procedure. The order should specify the diagnosis prompting the referral for a diagnostic mammogram. Diagnostic mammography should be performed under the direct, on-site supervision of an interpreting physician qualified in mammography. Diagnostic mammography may require that the performing radiologist review the history with the patient, review the prior mammograms, and perform an examination as part of the mammography. Also, the findings of the examination are typically discussed with the patient at the
completion of the mammogram. Therefore, if telemammography is being used with digital diagnostic mammography, the radiologist need not be present for the mammography; however, he/she must be available to discuss the history with the patient, examine the patient, and discuss results of the findings of the examination with the patient within an acceptable period of time. In the CY 2015 PFS Final Rule with comment period, CMS established a payment rate for the newly created CPT code 77063 for screening digital breast tomosynthesis mammography. The same policies that are applicable to other screening mammography codes are applicable to CPT code 77063. In addition, since this is an add-on code it should only be paid when furnished in conjunction with a 2D digital mammography. Effective January 1, 2015, HCPCS code 77063 (Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure)), must be billed in conjunction with the screening mammography HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views, 2D imaging only. Effective January 1, 2015, beneficiary coinsurance and deductible does not apply to claim lines with 77063 (Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure). Payment for 77063 is made only when billed with an ICD-9 code of V76.11 or V76.12 (and when ICD-10 is effective with ICD-10 code Z12.31). When denying claim lines for 77063 that are submitted without the appropriate diagnosis code, the claim lines are denied using the following messages: ** CARC 167: This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. ** RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.mcd.search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD. Group Code CO (if GZ modifier present) or PR (if modifier GA is present). On institutional claims: ** MACs will pay for tomosynthesis, HCPCS code 77063, on TOBs 12X, 13X, 22X, 23X based on MPFS, and TOB 85X with revenue code other than 096x, 097x, or 098x based on reasonable cost. TOB 85X claims with revenue code 096x, 097x, or 098x are paid based on MPFS (115% of the lesser of the fee schedule amount and submitted charge). ** MACs will pay for tomosynthesis, HCPCS code 77063 with revenue codes 096X, 097X, or 098X when billed on TOB 85X Method II based on 115% of the lesser of the fee schedule amount or submitted charge. ** MACs will return to the provider any claim submitted with tomosynthesis, HCPCS code 77063 when the TOB is not 12X, 13X, 22X, 23X, or 85X. ** MACs will pay for tomosynthesis, HCPCS code 77063, on institutional claims TOBs 12X, 13X, 22X, 23X, and 85X when submitted with revenue code 0403 and on professional claims TOB 85X when submitted with revenue code 096X, 097X, or 098X. ** Effective for claims with dates of service on or after January 1, 2015, MACs will RTP claims for HCPCS code 77063 that are not submitted with revenue code 0403, 096X, 097X, or 098X.
Billing and Coding Guidelines 77061 Digital breast tomosynthesis; unilateral 77062 bilateral +77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) (Do not report 77063 in conjunction with 76376, 76377, 77055, 77056) (Use 77063 in conjunction with 77057) Multiple radiology societies requested three new Category I codes to describe diagnostic (77061 and 77062) and screening (77063) digital breast tomosynthesis procedures. Current mammography codes do not include the added physician work or practice expense involved in digital breast tomosynthesis and, therefore, new codes were needed to describe these additional resources. Currently under the CMS FAQ issued in November 2013, tomosynthesis is not separately billable. The publication of Medicare’s Final Rule for 2015 this November will, we hope, clarify billing for tomosynthesis. The Health Plan considers 3D rendering of imaging studies to be a technology and technique improvement that represents an aid to the physician via computer generated real-time study interpretation and decision support. These visual enhancements are considered an elective component of the overall imaging study performed. Therefore, separate visual enhancements reported with CPT codes 76376 and 76377 are not eligible for separate reimbursement. The Health Plan also considers digital breast tomosynthesis (DBT) to be a visual enhancement technique therefore CPT codes 77061, 77062 and 77063 and Healthcare Common Procedure Coding System (HCPCS Level II) code G0279 are not eligible for reimbursement This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page. Applicable service codes: 77061, 77062, 77063, G0279 Breast Imaging as an Adjunct to Mammography Digital mammography is proven and medically necessary for patients with dense breast tissue. Breast Specific Gamma Imaging (Scintimammography) Scintimammography is unproven and not medically necessary for breast cancer screening or diagnosis. There is insufficient evidence that this diagnostic modality can differentiate benign from malignant breast lesions. Based on the evidence, the role of scintimammography remains unclear since this technology has not been shown to be accurate enough to screen for breast cancer or allow a confident decision to defer biopsy. Electrical Impedance Scanning (EIS) Electrical impedance scanning (EIS) is unproven and not medically necessary for the detection of breast cancer. There is insufficient evidence that EIS is effective in detecting malignant breast tissue. Evaluation of sensitivity and negative predictive value for EIS is inconsistent. Well-designed studies are needed to determine whether or not EIS is effective as an adjunct to mammography or provides a positive clinical benefit. Breast ultrasound is unproven and not medically necessary for routine breast cancer screening including patients with dense breast tissue. Clinical evidence has not yet demonstrated that routine use of ultrasonography as an adjunct to screening mammography reduces the mortality rate from breast cancer. Automated Breast Ultrasound Automated breast ultrasound is unproven and not medically necessary. Clinical evidence is insufficient to determine whether automated breast ultrasound improves the detection rate of breast cancer compared to screening mammography. Future research should include better-designed studies, including prospective studies and randomized controlled trials evaluating this technology. CPT Code Description 0159T Computer aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary procedure) HCPCS Code Description G0202 Screening mammography, bilateral (2-view study of each breast), including computer-aided
detection (CAD) when performed Mammography is a specific type of imaging that uses a low-dose x-ray system for examination of the breasts. This is considered the best available method for early detection of breast cancer, particularly in the case of small or nonpalpable lesions. An abnormal screening mammogram requires a diagnostic test to confirm whether cancer is present. Lesions that are suggestive of cancer are evaluated with tissue biopsy. If a noninvasive diagnostic test is available that can accurately exclude cancer; many women with an abnormal mammogram could avoid biopsy. Therefore, efforts to develop adjuvant imaging procedures continue. This policy will focus on magnetic resonance elastography, scintimammography, electrical impedance scanning and computer-aided detection for MRI, automated breast ultrasound and ultrasound for breast cancer screening and the diagnosis of breast cancer. The National Cancer Institute estimates that about 40 percent of women undergoing screening mammography have dense breasts. These women have an increased risk of breast cancer, with detection usually at a more advanced and difficult to treat stage. Mammography is a low-dose X-ray imaging method of the breast. However, mammograms of dense breasts can be difficult to interpret. Fibroglandular breast tissue and tumors both appear as solid white areas on mammograms. As a result, dense breast tissue may obscure smaller tumors, potentially delaying detection of breast cancer. ICD-10-CM Codes Who Is Covered Frequency • Aged 35 through 39: One baseline; or Beneficiary Pays • Copayment/coinsurance waived • Deductible waived G0202 Screening mammography, producing direct digital image, bilateral, all views. Code Effective April 1, 2001. Screening Digital Breast Tomosynthesis
What does CPT code 77067 mean?77067. SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW STUDY OF EACH BREAST), INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PERFORMED.
What is the CPT code 77063?77063, Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure).
What is the difference between 3D mammogram and diagnostic mammogram?While bilateral mammograms take one image from the top and one image from the side, 3D mammography takes many. A 3D mammogram machine moves in an arc to take multiple low-dose x-rays of the breast from different angles.
What is the difference between CPT code 77062 and 77063?Assign CPT code 77061 when DBT is performed on one breast and CPT code 77062 when DBT is performed on both breasts. Use code 77063 for bilateral screening DBT performed in addition to a primary procedure. Do not report 77061, 77062 in conjunction with 76376 or 76377 (three-dimensional reconstruction).
What is the difference between 3D mammography and tomosynthesis?Tomosynthesis or “3D” mammography is a new type of digital x-ray mammogram which creates 2D and 3D-like pictures of the breasts. This tool improves the ability of mammography to detect early breast cancers, and decreases the number of women “called back” for additional tests for findings that are not cancers.
What is the difference between Z12 31 and Z12 39?Z12. 31 (Encounter for screening mammogram for malignant neoplasm of breast) is reported for screening mammograms while Z12. 39 (Encounter for other screening for malignant neoplasm of breast) has been established for reporting screening studies for breast cancer outside the scope of mammograms.
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