Billing Requirements - A/B MAC (A) Claims

20.4 - Billing Requirements - A/B MAC (A) Claims (Rev. 3844, Issued: 08-18-17, Effective: 01-01-18, Implementation: 01-02-18) A/B MACs use the weekly-updated MQSA file to verify that the billing facility is certified by the FDA to perform mammography services, and has the appropriate certification to perform the type of mammogram billed (film and/or digital). (See §20.1.) A/B MACs (A) use the provider number submitted on the claim to identify the facility and use the MQSA data file to verify the facility’s certification(s). A/B MAC (A) complete the following activities in processing mammography claims: • If the provider number on the claim does not correspond with a certified mammography facility on the MQSA file, then A/B MACs (A) deny the claim. • When a film mammography HCPCS code is on a claim, the claim is checked for a “1” film indicator. • If a film mammography HCPCS code comes in on a claim and the facility is certified for film mammography, the claim is paid if all other relevant Medicare criteria are met. • If a film mammography HCPCS code is on a claim and the facility is certified for digital mammography only, the claim is denied. • When a digital mammography HCPCS code is on a claim, the claim is checked for “2” digital indicator. • If a digital mammography HCPCS code is on a claim and the facility is certified for digital mammography, the claim is paid if all other relevant Medicare criteria are met. • If a digital mammography HCPCS code is on a claim and the facility is certified for film mammography only, the claim is denied. NOTE: The Common Working File (CWF) no longer receives the mammography file for editing purposes. Except as provided in the following sections for RHCs and FQHCs, the following procedures apply to billing for screening mammographies: The technical component portion of the screening mammography is billed on Form CMS-1450 under bill type 12X, 13X, 14X**, 22X, 23X or 85X using revenue code 0403 and HCPCS code 77067* (G0202*). The technical component portion of the diagnostic mammography is billed on Form CMS-1450 under bill type 12X, 13X, 14X**, 22X, 23X or 85X using revenue code 0401 and HCPCS code 77065* (G0206*),* 77066*(G0204). Separate bills are required for claims for screening mammographies with dates of service prior to January 1, 2002. Providers include on the bill only charges for the screening mammography. Separate bills are not required for claims for screening mammographies with dates of service on or after January 1, 2002. See separate instructions below for rural health clinics (RHCs) and federally qualified health centers (FQHCs). * For claims with dates of service January 1, 2017 through December 31, 2017, providers report CPT codes G0202, G0204, and G0206. For claims with dates of service January 1, 2018 and later, providers report CPT codes 77067, 77066, and 77065 respectively. ** For claims with dates of service April 1, 2005 and later, hospitals bill for all mammography services under the 13X type of bill or for dates of service April 1, 2007 and later, 12X or 13X as appropriate. The 14X type of bill is no longer applicable. Appropriate bill types for providers other than hospitals are 22X, 23X, and 85X. In cases where screening mammography services are self-referred and as a result an attending physician NPI is not available, the provider shall duplicate their facility NPI in the attending physician identifier field on the claim.