Mammograms Performed With New Technologies

20.7 - Mammograms Performed With New Technologies (Rev. 3844, Issued: 08-18-17, Effective: 01-01-18, Implementation: 01-02-18) Section 104 of the Benefits Improvement and Protection Act 2000, (BIPA) entitled Modernization of Screening Mammography Benefit, provides for new payment methodologies for both diagnostic and screening mammograms that utilize advanced new technologies for the period April 1, 2001, to December 31, 2001 (to March 31, 2002 for hospitals subject to OPPS). Under this provision, payment for technologies that directly take digital images would equal 150 percent of the amount that would otherwise be paid for a bilateral diagnostic mammography. For technologies that convert standard film images to digital form, payment will be derived from the statutory screening mammography limit plus an additional payment of $15.00 for A/B MACs (B) claims and $10.20 for A/B MAC (A) (technical component only) claims. Payment restrictions for digital screening and diagnostic mammography apply to those facilities that meet all FDA certifications as provided under the Mammography Quality Standards Act. However, CAD codes billed in conjunction with digital mammographies or film mammographies are not subject to FDA certification requirements. Payment Requirements for Claims with Dates of Service on or After January 1, 2002 (April 1, 2002 for hospitals subject to OPPS). A/B MAC (A) Payment Code Payment 77067* (G0202*) Payment will be equal to the lower of the actual charge or the locality specific technical component payment amount under the MPFS when performed in a hospital outpatient department, CAH, or SNF. Deductible and coinsurance do not apply. 77066* (G0204*) Payment will be made under OPPS for hospital outpatient departments. Coinsurance is the national unadjusted coinsurance for the APC wage adjusted for the specific hospital. Payment will be made on a reasonable cost basis for CAHs and coinsurance is based on charges. Payment is made under the MPFS when performed in a SNF and coinsurance is 20 percent of the lower of the actual charge or the MPFS amount. Deductible applies. NOTE: Effective January 1, 2005, payment will be made under MPFS for claims from hospitals subject to OPPS. 77065* (G0206*) Payment will be made under OPPS for hospital outpatient departments. Coinsurance is the national unadjusted coinsurance for the APC wage adjusted for the specific hospital. Payment will be made on a reasonable cost basis for CAHs and coinsurance is based on charges. Payment is made under the MPFS when performed in a SNF. Coinsurance is 20 percent of the lower of the actual charge or the MPFS amount. Deductible applies. NOTE: Effective January 1, 2005, payment will be made under MPFS for claims from hospitals subject to OPPS. Institutional providers bill for the technical portion of screening and diagnostic mammograms on Form CMS-1450 (or electronic equivalent) under bill type 13X, 22X, 23X, or 85X. Institutional providers bill for digital screening mammographies on Form CMS-1450, utilizing revenue code 0403 and HCPCS G0202 or G0203. Institutional providers bill for digital diagnostic mammographies on Form CMS-1450, utilizing revenue code 0401 and HCPCS G0204, G0205, G0206 or G0207. NOTE: Codes G0203, G0205 and G0207 are not billable codes for claims with dates of service on or after January 1, 2002. CAHs electing the optional method of payment for outpatient services are paid according to §20.3.2.3 of this chapter. A/B MACs (B) Payment All codes paid by the A/B MACs (B) are based on the Medicare Physician Fee Schedule (MPFS). Code Payment 77067* (G0202*) Payment is the lesser of the provider’s charge or the MPFS amount provided for this code in the pricing file. Part B deductible does not apply, however, coinsurance applies. 77066* (G0204*) Payment is the lesser of the provider’s charge or the MPFS amount provided for this code in the pricing file. Deductible and coinsurance apply. 77065* (G0206*) Payment is the lesser of the provider’s charge or the MPFS amount provided for this code in the pricing file. Deductible and coinsurance apply. The professional component is billed to the A/B MACs (B) on Form CMS-1500 (or electronic equivalent). A/B MACs (A) and (B) were furnished a mammography benefit pricing file to pay claims containing the above codes.