This advisory discusses coding, coverage, and payment for mammography services provided in the
hospital outpatient, independent diagnostic testing facility (IDTF), and physician office settings2,3 While
it focuses on Medicare program policies, these policies may be applicable to selected private payers
throughout the country.
For purposes of this advisory, diagnostic mammography refers to a radiologic procedure furnished to a
man or woman with signs or symptoms of breast disease, a personal history of breast cancer or a personal
history of biopsy-proven benign breast disease. Screening mammography refers to a radiologic
procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early
detection of breast cancer.
Coding
Medicare’s reimbursement system relies mostly on Current Procedural Terminology (CPT) codes to consistently identify some mammography services provided to Medicare patients. 5 The CPT
coding system was developed and is maintained by the American Medical Association (AMA) and the codes are updated annually.
In addition to the use of CPT codes, Medicare utilizes Healthcare Common Procedure Coding System (HCPCS) Level II (national) codes to report digital mammography services. The agency developed the alphanumeric HCPCS level II coding system to describe and identify many supplies and services that are not included in the CPT coding system. Table 1 lists the CPT codes and HCPCS Level II codes that should be reported for mammography services.
Medicare also reimburses for computer-aided detection (CAD) as a separate, add-on payment when used with either film-based or digital mammography. The CPT codes for CAD, listed in Table 1, distinguish between diagnostic and screening mammography applications.
For diagnostic services, it should be noted that the CAD CPT code 77051 can be reported in conjunction with the primary service mammography CPT codes 77055 or 77056, as well as HCPCS codes G0204 or G0206. For screening services, CAD CPT code 77052 can be reported in conjunction with the primary service mammography code, CPT code 77057 or HCPCS code G0202.
Medicare will reimburse providers for medically necessary screening and diagnostic mammography procedures 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.
Reimbursement
Medicare reimbursement for mammography services, including the add-on payment for CAD, is comprised of a professional component, the amount paid for the physician’s interpretation and report, and a technical component, the amount paid for all other services (including staffing and equipment costs). When combined and paid to the same individual or entity, this amount is often referred to as the total or global reimbursement. Regardless of the site of service, diagnostic and screening mammography services are paid under the Medicare physician fee schedule.
Table 1 ( See the next post) provides information concerning Medicare national payment amounts for both screening and diagnostic mammography services performed in the hospital outpatient department, IDTF and physician office sites of care. Note that Medicare payment amounts and coverage policies for specific procedures will vary by geographic location. For more information about reimbursement rates in your area, consult your local Medicare contractor.