In just a few weeks, radiology providers should know what changes the U.S. Centers for Medicare and Medicaid Services (CMS) intend to finalize for 2015 related to digital mammography and breast tomosynthesis. Answers to the following decisions should be included in the 2015 final rule for the Medicare Physician Fee Schedule (MPFS), which is usually available by November 1:
- Will Medicare separately pay for the following new CPT codes for digital breast tomosynthesis?
- 77061: Digital breast tomosynthesis; unilateral
- 77062: Digital breast tomosynthesis; bilateral
- 77063: Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure)
- Will CMS delete the following temporary Healthcare Common Procedure Coding System (HCPCS) level II codes?
- G0202: Screening mammography, producing direct digital image, bilateral, all views
- G0204: Diagnostic mammography, producing direct digital image, bilateral, all views
- G0206: Diagnostic mammography, producing direct digital image, unilateral, all views
Currently, most payors consider 3D digital breast tomosynthesis to be an investigational procedure and, therefore, not covered -- even though, for data-collection purposes, it should still be reported when performed.
Reason for new codes
At the request of RSNA, the American College of Radiology (ACR), and the American Roentgen Ray Society (ARRS), the American Medical Association (AMA) established codes 77061, 77062, and 77063 to address diagnostic and screening breast tomosynthesis.
The need for new codes was obvious, according to ACR: The current mammography CPT codes (77055-77057) do not include the added physician work or practice expense (PE) involved in breast tomosynthesis.
Digital mammography with breast tomosynthesis involves "two separate data acquisitions with two different sets of images, requiring the accompanying increased physician work and training," the association explained. "Digital mammography alone requires a single data acquisition per view, producing one image set involving less physician work and training to interpret."
Until now, no separate CPT codes existed for breast tomosynthesis, and providers assigned unlisted diagnostic radiographic procedure code 76499. In the June 2011 edition of Radiology Coding Source, ACR gave the following guidance:
Breast tomosynthesis performed in conjunction with digital mammography is appropriately reported with the unlisted diagnostic procedure code 76499 to describe breast tomosynthesis and one of the HCPCS level II "G" codes (G0202, G0204, or G0206) to describe the full-field digital mammography performed. If computer-aided detection (CAD) is also performed, it should be reported separately using one of the mammography CAD codes, 77051 (CAD performed in conjunction with diagnostic mammography) or 77052 (CAD performed in conjunction with screening mammography).
Coding policy overview
Currently, providers report and are paid for mammography services using both film and digital technology. For film, the following CPT codes are reported:
- 77055: Mammography; unilateral
- 77056: Mammography; bilateral
- 77057: Screening mammography, bilateral (two-view film study of each breast)
In 2002, CMS responded to special payment rules for digital mammography included in the Benefits Improvement and Protection Act (BIPA) of 2000 and established temporary level II codes G0202-G0206 for mammography services using new digital technologies. Now, in the 2015 MPFS, CMS proposed that the G-codes be deleted and that all mammography be billed with the existing mammography CPT codes 77055-77057.
According to CMS, "a review of Medicare claims data shows that the mammography CPT codes are billed extremely infrequently, and that the G-codes are billed for the vast majority of mammography claims."
CMS has proposed using the relative value units (RVUs) previously established for the G-codes to value the mammography CPT codes. Because these codes are potentially misvalued, the agency requested that the Relative Value Scale Update Committee (RUC) and other interested stakeholders review these services in terms of appropriate work RVUs, work time assumptions, and direct PE inputs.
In the proposed MPFS rule for 2015, CMS reports that AMA's RUC recommended that the direct practice expense inputs for all imaging codes be adjusted to reflect the migration from film to digital storage technologies since digital storage is now typically used in imaging. The agency stated that its research confirmed that the overwhelming majority of mammography is digital.
As a result, it proposed that for 2015, CPT codes 77055, 77056, and 77057 be used for reporting mammography to Medicare regardless of whether film or digital technology is used. It also proposed to delete HCPCS codes G0202, G0204, and G0206, and that the values established for the digital mammography G-codes be used for the CPT codes.
CMS also reported that the G-code values it proposed to use for the CPT codes for 2015 have not been reviewed since they were created in 2002. Therefore, it proposed to include CPT codes 77055, 77056, and 77057 on the list of potentially misvalued codes, which could mean lower reimbursement.
ACR urged CMS to consider the "downstream consequences" of deleting the G-codes and using only the CPT codes. It explains as follows:
Medicaid and most private payors will lack sufficient time to update their fee schedules to apply the G-code payment amounts to the analog codes. As such, payment rates for digital mammography could decrease significantly, possibly jeopardizing patient access, especially in the outpatient setting.
Tips for code assignment
The 2015 CPT code manual includes parenthetical guidelines related to codes that may be reported with these additions and codes that should not be reported with them. Specifically, AMA states that 77061 and 77062 should not be reported with 76376, 76377, or 77057. Code 77063 should not be reported with 76376, 76377, 77055, or 77056. However, 77063 may be reported with 77057.
Radiology providers should contact their Medicare and non-Medicare payors for coverage and billing guidance for these and all new codes. Commercial payors set their own policies and rates and do not necessarily follow Medicare's policy, although some do.
If an insurer does not cover this procedure, providers may ask patients to sign an advance beneficiary notice (ABN). By signing, patients acknowledge that the service may not be covered and they will assume financial responsibility. Patients also may choose to accept or decline breast tomosynthesis on the ABN.
However, note that technically the ABN is a Medicare "device." Many non-Medicare payors restrict whether or not a provider can bill a patient if a claim is denied as not covered, and having a signed ABN would not matter.
Jeff Majchrzak is vice president of clinical consulting services, radiology, for Panacea Healthcare Solutions. In his role as consultant, he conducts CPT coding assessments for both hospitals and physicians, evaluates administrative policies and procedures, and helps develop quality assurance programs to ensure complete and compliant coding and billing. Jeff trains both radiology and cardiology staff (on both technical and professional billing issues) in correct coding practices. Jeff contributes to numerous publications by MedLearn Publishing (a division of Panacea) and is a sought-after national speaker on coding and reimbursement for radiology, interventional radiology, nuclear medicine, and cardiology. Jeff can be reached at email@example.com, or visit Panacea Healthcare Solutions at www.panaceahealthsolutions.com.