Billing Requirements - A/B MAC (B) Claims

20.5 - Billing Requirements - A/B MAC (B) Claims (Rev. 3329, Issued: 08-14-15, Effective: 01-01-12, Implementation: 09-14-15) A/B MACs (B) use the weekly-updated 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). A/B MACs (B) match the FDA assigned, 6-digit mammography certification number on the claim to the FDA mammography certification number appearing on the file for the billing facility. A/B MACs (B) complete the following activities in processing mammography claims: • If the claim does not contain the facility’s 6-digit certification number, then A/B MACs (B) return the claim as unprocessable. • If the claim contains a 6-digit certification number that is reported in the proper field or segment (as specified in the previous bullet) but such number does not correspond to the number specified in the MQSA file for the facility, then A/B MACs (B) 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. • Process the claim to the point of payment based on the information provided on the claim and in A/B MAC (B) claims history. • Identify the claim as a screening mammography claim by the CPT-4 code and diagnosis code(s) listed on the claim. • Assign physician specialty code 45 to facilities that are certified to perform only screening mammography. • Ensure that entities that bill globally for screening mammography contain a blank in modifier position #1. • Ensure that entities that bill for the technical component use only HCPCS modifier “-TC.” • Ensure that physicians who bill the professional component separately use HCPCS modifier “-26.” • Ensure all those who are qualified include the 6-digit FDA-assigned certification number of the screening center on the claim. Providers report this number in item 32 on the paper 1500 claim form. A/B MACs (B) retain this number in their provider files. • When a mammography claim contains services subject to the anti-markup payment limitation and the service was acquired from another billing jurisdiction, the provider must submit their own NPI with the name, address, and ZIP code of the performing physician/supplier. • Refer to Pub. 100-04, chapter 1, section 10.1.1.1., for claims processing instructions for payment jurisdiction. • Beginning October 1, 2003, A/B MACs (B) are no longer permitted to add the diagnosis code for a screening mammography when the screening mammography claim has no diagnosis code. Screening mammography claims with no diagnosis code must be returned as unprocessable for assigned claims. For unassigned claims, deny the claim. A/B MAC (B) Provider Education • Educate providers that when a screening mammography turns to a diagnostic mammography on the same day for the same beneficiary, add the “-GG” modifier to the diagnostic code and bill both codes on the same claim. Both services are reimbursable by Medicare. • Educate providers that they cannot bill an add-on code without also billing for the appropriate mammography code. If just the add-on code is billed, the service will be denied. Both the add-on code and the appropriate mammography code should be on the same claim. • Educate providers to submit their own NPI in place of an attending/referring physician NPI in cases where screening mammography services are self-referred.