Medicare Claims Processing Manual (Pub. 100-04), Ch. 18 § 20.3.1.2.1
CAH Screening Mammography Payment Table
20.3.1.2.1 - CAH Screening Mammography Payment Table
(Rev. 3844, Issued: 08-18-17, Effective: 01-01-18, Implementation: 01-02-18)
Payment for Screening Mammography in the Critical Access Hospital Outpatient Setting
Method 1 (Standard)
TOB
Rev
Code
HCPCS
Payment
Services on or after January 1 2002
Technical Component
Deductible does not apply.
Coinsurance based on charge.
85X
403
77067*
(G0202)*
A/B MAC (A)
payment is 80%
of the lower of
the charge or the
fee schedule
amount.
Professional Component
Deductible does not apply.
Coinsurance based on lower of MPFS
or charge.
77067*
(G0202)*
A/B MACs (B)
payment is 80%
of the lower of
the charge or
MPFS amount
for the technical
component. The
new A3 states
payment for
76092 is lower of
charge or locality
specific
TECHNICAL
component
amount under
MPFS.
Method 2 (Optional Method) - Option available with cost reporting periods starting on or
after October 1, 2001 and dates of service on or after July 1, 2001.
TOB
Rev
Code
HCPCS
Payment
Services on or after January 1 2002
Technical Component
Deductible does not apply.
Coinsurance based on charge.
85X
403
77067*
(G0202)*
A/B MAC (A)
payment is 80%
of the lower of
the charge or the
fee schedule
amount.
Professional Component
Deductible does not apply.
Coinsurance based on lower of
MPFS or charge.
85X
96X,
97X,
or 98X
77067*
(G0202*)
A/B MAC (A)
pays 115% of
80% (that is 92%)
of the lower of
the charge or the
MPFS amount.