(Medicare Claims Processing Manual)

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 facilitys 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.   20.5.1 - A/B MACs (B)  Claim Record for CWF  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) B3-4601.3.B  A/B MACs (B) complete the type of service field in the CWF Part B claim record with a B if the patient is a high risk screening mammography patient or a C if she is a low risk screening mammography patient for services prior to January 1, 1998. For services on or after January 1, 1998, the type of service field on CWF must have a value of 1 for medical care (screening) or a 4 for diagnostic radiology (diagnostic).  Fill in POS.  Fill in deductible indicator field with a 1; not subject to de ductible if screening mammography.  Submit the claim to the CWF host.  Trailer 17 of the Part B Basic Reply record will give the date of the last screening mammography. The CWF edits for age and frequency for screening mammography.  There are no frequency limitations on diagnostic tests.    20.5.2 - Transportation Costs for Mobile Units  (Rev. 1, 10- 01-03)  B3-4601.2.J  Transportation costs are associated with mobile units for diagnostic mammography tests only.  CMS formally added diagnostic mammography to the regulation language of the portable x- ray benefit in 42 CFR 410.32(c)(3) .  These units are usually reserved for screening tests only.  For the screening tests performed in a mobile unit, there is no separate transportation cost allowed.  A/B MACs (B) should investigate transportation costs associated with the mobile mammography diagnostic tests that exceed data analysis guidelines.   To receive transportation payments, the approved portable x- ray supplier must also meet the certification requirements of 354 of the Public Health Service Act.   20.6 - Instructions When an Interpretation Results in Additional Films  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the screening exam.  When a radiologists interpretation results in additional films, Medicare will pay for bot h the screening and diagnostic mammogram. A/B MACs (B)  Claims  For A/B MACs (B) claims, providers submitting a claim for a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier  -GG to the diagnostic mammography.  A modifier  -GG is appended to the claim for the dia gnostic mammogram for tracking and data collection purposes.  Medicare will reimburse both the screening mammography and the diagnostic mammography.  A/B MAC (A) Claims  A/B MACs (A) require the diagnostic claim be prepared reflecting the diagnostic revenue code (0401) along with HCPCS code 77065*(G0206*), 77066*(G0204*), or G0279 and modifier  -GG  Performance and payment of a screening mammogram and diagnostic mammogram on the same  patient, same day. Reporting of this modifier is needed for data collection purposes.  Regular billing instructions remain in place for a screening mammography that does not fit this situation.  Both A/B MACs (A) and (B) systems must accept the GH and GG modifiers where appropriate.  * For  claims with dates of service prior to January 1, 2017 thru December 31, 2017, providers report CPT codes G0206 and G0204.  For claims with dates of service January 1, 2018 and later, providers report CPT codes 77065 and 77066 respectively.   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 bil ateral 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 perfor med 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.  Code  Payment  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 providers 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 providers 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 providers charge or the MPFS amount provided for this code in the pricing file. Code  Payment  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.  20.8 - Beneficiary and Provider Notices  (Rev. 1, 10- 01-03)