(Medicare Claims Processing Manual)

20.2.1 - Digital Breast Tomosynthesis  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) A. Screening Breast Tomosynthesis  Effective for claims with dates of service January 1, 2017 through December 31, 2017, HCPCS code 77063, Screening Digital Breast Tomosynthesis, bilateral, must be billed in conjunction with the primary service mammogram code G0202. Effective for claims wi th dates of service January 1, 2018 and later HCPCS code 77063, Screening Digital Breast Tomosynthesis, bilateral, must be billed in conjunction with the primary service mammogram code 77067.   A/B MACs (A) and (B) must assure that claims containing code 77063 also contain HCPCS code 77067* (G0202*).  A/B MACs (A) return claims containing code 77063 that do not also contain HCPCS code 77067* (G0202*)with an explanation that payment for code 77063 cannot be made when billed alone.  A/B MACs (B) deny payment for 77063 when billed without 77067* (G0202*).  NOTE:  When screening digital breast tomosynthesis, code  77063, is billed in conjunction with a screening mammography, code 77067* (G0202*), and the screening mammography 77067* (G0202*) fails the age and frequency edits in CWF, both services will be rejected by CWF.  B. Diagnostic Breast Tomosynthesis  Effective with claims with dates of service January 1, 2017 through December 31, 2017 HCPCS code G0279, Diagnostic digital breast tomosynthesis, unilateral or bilateral, must be billed in conjunction with the primary service mammogram code G0204 or G0206.  Effective with claims with dates of service January 1, 2018 and later, HCPCS code G0279, Diagnostic digital breast tomosynthesis, unilateral or bilateral, must be billed in conjunction with the primary service mammogram code 77065 or 77066.Effective f or claims with dates of service January 1, 2017 through December 31, 2017 A/B MACs (A) and (B) must assure that claims containing code G0279 also contain HCPCS code G0204 or G0206.  A/B MACs (A) or (B) deny claims containing code G0279 that do not also contain HCPCS code G0202 or G0206 with an explanation that payment for code G0279 cannot be made when billed alone.  Effective for claims with dates of service January 1, 2018 and later A/B MACs (A) and (B) must assure that claims containing code G0279 also c ontain HCPCS code 77065 or 77066.  A/B MACs (A) or (B) deny claims containing code G0279 that do not also contain HCPCS code 77065 or 77066 with an explanation that payment for code G0279 cannot be made when billed alone.   Claims for diagnostic breast tomosynthesis, HCPCS code G0279, submitted with a revenue code other than 0401, 096X, 097X, or 098X will be return to providers.   Claims for diagnostic breast tomosynthesis, HCPCS code G0279, submitted with a TOB other than 12X, 13X, 22X, 23X, or 85X will be return to providers.   20.2.2 - Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18)  When denying claim lines for HCPCS code 77063 that are not submitted with the diagnosis code V76.11 or V76.12, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CAR C/RARC combination is compliant with CAQH CORE Business Scenario Three.   CARC: 167  RARC: N386  MSN: 14.9 Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed ABN is on file).  Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file). When denying claim lines for HCPCS code G0279 that are not submitted with HCPCS 77066 or 77065   20.3 - Payment  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) There is no Part B deductible or coinsurance for screening mammographies.  The anti -markup payment limitation on physician billing for diagnostic tests does not apply to these services.  Following are three categories of billing for mammography services:   Professional component of mammography services (that is the physicians interpretation of the results of the examination);   Technical component (all other services); or    Both professional and technical components (global).  However, global billing is not permitted for services furnished in provider outpatient departments, except for CAHs electing the optional method of payment for mammography services furnished on or after  January 1, 2002.   20.3.1 - Payment for Screening Mammography Services Provided On and After January 1, 2002  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) The payment limitation methodology does not apply to claims with dates of service on or after January 1, 2002.  A/B MAC (A) Claims  For claims with dates of service on or after January 1, 2002, 104 of the Benefits Improvement and Protection Act (BIPA) 2000, provides for payment of screening mammography under the Medicare physician fee schedule (MPFS) when furnished in hospitals, skill ed nursing facilities (SNFs), and CAHs not electing the optional method of payment for outpatient services.  However, payment under the physician fee schedule is not applicable to hospitals subject to the Outpatient Prospective Payment System (OPPS) until April 1, 2002.  The payment for code 77067* is equal to the lower of:   The actual charge or    Locality specific technical component payment amount under the MPFS.  Part B deductible and coinsurance does not apply.  This is a final payment.  A/B MACs (A) use the benefit -pricing file provided by CMS to pay mammography codes.  Payment for the add- on code 76085 is made under the Medicare Physician Fee Schedule.  Deductible does not apply, however, coinsurance is applicable.  *For  claims with dates of service prior to January 1, 2007, providers report CPT code 76092.  For claims with dates of service January 1, 2007 and later, providers report CPT code 77057.  A/B MACs (B) Claims  Physicians and suppliers are paid by the A/B MACs (B) for all mammography tests (including screening mammography) under the MPFS.  Separate prices for the technical component, the professional component and the global service are included on the MPFS.  The Medicare allowed charge is the lower of:   The actual charge, or    The MPFS amount for the service billed. The Medicare payment for the service is 80 percent of the allowed charge.  Coinsurance is 20 percent of the lower of the actual charge or the MPFS amount.  Part B deductible is waived and does not apply to screening mammography. As with other MPFS services, the nonparticipating provider reduction and the limiting charge provisions apply to all mammography tests (including screening mammography).   20.3.1.1 - Outpatient Hospital Mammography Payment Table  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) Payment for screening mammography in the Hospital Outpatient Setting (Revenue code 403) is the lesser of charge, or TC of MPFS for code 77067* (G0202*). Neither  deductible nor a coinsurance applies.   Payment for diagnostic mammography, bilateral in the Hospital Outpatient Setting (Revenue code 401) is the lesser of charge, or TC of MPFS for code 77066* (G0204*).   Payment for diagnostic mammography, unilateral in the Hospital Outpatient Setting (Revenue code 401) is the lesser of charge, or TC of MPFS for code 77065* (G0206*).  Deductible and coinsurance apply.  Beginning January 1, 2005, Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, 644, Public Law 108- 173 has changed the way Medicare pays for diagnostic mammography.  Medicare payment will be based on the MPFS.  Payment will no longer be made under the OPPS.  20.3.1.2 - Critical Access Hospital Payment  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) Payment to a CAH for screening mammography is not subject to applicable Part B deductible, but coinsurance does apply.  Any deductible or coinsurance collected is deducted from the payment. A.  Under the Optional (All Inclusive) Method Section 403(d) of the BBRA amended 1834(g)  of the Act to permit a CAH to elect an optional method of payment for outpatient services.  This option is effective for cost reporting periods beginning on or after October 1, 2001.  A CAH may elect to be paid for outpatient services by reasonable costs for facility services and 202 of BIPA allows an amount equal to 115 percent of the allowed amount for professional component.  (Costs related to professional services are excluded from the cost payment.)  CAHs electing the optional method of reimbursement bill the A/B MAC (A) with type of bill 85X, revenue code 0403 and HCPCS code 77067* (G0202*).  They also include the professional component on a separate line, with revenue code 96X, 97X, or 98X and HCPCS code 77067* (G0202*).  B. Under the Standard Method CAHs reimbursed on the standard method of payment bill the technical component of a screening mammography to the A/B MAC (A) on type of bill 85X, revenue code 0403 and HCPCS code 77067* (G0202*).  Professional services are billed to the A/B MAC (B) and paid based on the fee schedule by the A/B MAC (B).  For claims with dates of service on or after January 1, 2002, 104 of the Benefits Improvement and Protection Act (BIPA) 2000, provides for payment of screening mammographies under the Medicare physician fee schedule (MPFS) in CAHs not electing the optiona l method of payment for outpatient services.  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.