(Medicare Claims Processing Manual)

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.   Method 2 (Optional Method) -  Option available with cost reporting periods starting on or after October 1, 2001 and dates of service on or after July 1, 2001.   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.  85X 96X, 97X, or 98X  77067* (G0202*)  A/B MAC (A) pays 115% of 80% (that is 92%) of the lower of the charge or the MPFS amount.  20.3.1.3 - SNF Mammography Payment   (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) Payment for screening mammography in a SNF is equal to the lower of:  charge, or TC of MPFS for code 77067.   No deductible, coinsurance applies.   Payment for diagnostic mammography, bilateral in a SNF is equal to the lower of: charge, or TC of MPFS for code 77066* (G0204*).   Deductible and coinsurance apply.  Payment for diagnostic mammography, unilateral in a SNF is equal to the lower of: charge, or TC of MPFS for code 77065* (G0206*).   Deductible and coinsurance apply.   20.3.1.4 - Independent Diagnostic Testing Facility (IDTF) Mammography Payment  (Rev. 4071, Issued: 06- 08-18, Issued: 07- 09-18, Implementation: 07- 09-18)  If an IDTF furnishes any type of mammography service (Screening or  diagnostic), it must have a Food and Drug Administration (FDA) certification to perform such services. An entity that only performs diagnostic mammography service should not be enrolled as an IDTF.  Screening mammographies (including those that are self -referred) are payable by Medicare when performed in and by an IDTF entity.  For additional information, refer to 100- 04  Medicare Claims Processing Manual, Chapter 35 Independent Diagnostic Testing Facility, Section 10.2  Claims Processing.     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 M ACs (A) use the provider number submitted on the claim to identify the facility and use the MQSA data file to verify the facilitys 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. A ppropriate 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.   20.4.1 - Rural Health Clinics and Federally Qualified Health Centers (Rev. 4225, Issues: 02 -01-19, Effective: 07- 01-19, Implementation: 07- 01-19)  A. Provider -Based RHC & FQHC -  Technical Component  The technical component of a screening or diagnostic mammography is outside the scope of the RHC/FQHC benefit.   In a provider -based RHC or FQHC, the technical component is billed by the base provider to the A/B MAC (A) under bill type 12X, 13X, 22X, 23X or  85X as appropriate using the base providers outpatient provider number (not the RHC/FQHC provider number).  The revenue code for a screening mammography is 0403, and the HCPCS code is 77067*, (G0202)*).  The revenue code for a diagnostic mammography is 0401, and the HCPCS codes are 77065* (G0206*), 77066* (G0204*).   Payment is based on the payment method for the base provider.   **G0236 is a deleted code after December 31, 2003.  Use 76082* for claims with dates of service January 1, 2004 through December 31, 2006, and code 77051 for claims with dates of service January 1, 2007 and later. * For  claims with dates of service January 1, 2017 through December 31, 2017, report CPT codes G0206, G0204, and G0202. For claims with dates of service January 1, 2018 and later, report CPT codes 77065, 77066, and 77067respectively.   B. Independent RHCs and Freestanding FQHCs -  Technical Component  The technical component of a screening or diagnostic mammography is outside the scope of the RHC/FQHC benefit.  The practitioner that renders the technical service bills their A/B MACs (B) using Form CMS -1500.  Payment is based on the MPFS national non-  facility rate.   C. Provider -Based RHC & FQHC, Independent RHCs and Freestanding FQHCs -  Professional Component  The professional component of a screening or diagnostic mammography is within the scope of the RHC/FQHC benefit and is billed under the RHC AIR or the FQHC PPS payment methodology with revenue code 052X. A/B MACs (A) should assure payment is not made for r evenue code 0403 (screening mammography) or 0401 (diagnostic mammography). No payment is made on the line item reporting revenue code 0403.   For claims with dates of service on or after April 1, 2005, RHCs and FQHCs bill the A/B MAC (A) under bill type 71X or 77X for the professional component of a diagnostic mammography. No payment is made for the professional component of a diagnostic mammography unless there is a qualifying visit on the same day. The services should be billed with the appropriate revenue code.   HCPCS coding is required for the diagnostic mammography.   20.4.2 - A/B MAC (A) Requirements for Nondigital Screening Mammographies (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) The A/B MAC (A) will consider the following when determining whether payment may be made:   Presence of revenue code 0403;    Presence of HCPCS code 77067* (G0206*);    Presence of high risk diagnosis code indicator where appropriate;    Date of last screening mammography; and   Age of beneficiary.   The A/B MACs (A) must accept revenue code 0403 for bill types 13X, 22X, 23X, 71X, 73X, or 85X. * For  claims with dates of service January 1, 2017 thru December 31, 2017 providers report HCPCS code G0206.  For claims with dates of service January 1, 2018 and later, providers report CPT code 77067.  20.4.2.1 - A/B MAC (A) Data for CWF and the Provider Statistical and Reimbursement Report (PS&R)  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) The CWF records are annotated with the date of the first (technical) screening mammography claim received.  The record is updated based on the next covered (technical) claim received.  A/B MACs (A) and (B) assume the claim is the first received for the ben eficiary where records do not contain a date of last screening and process accordingly. The A/B MACs (A) include revenue code, HCPCS code, units, and covered charges in the CWF record fields with the same name.  They report the payment amount for revenue code 0403 in the CWF field named Rate and the billed charges in the field named Charges of the CWF record.  In addition, A/B MACs (A) report special override code 1 in the field named Special Action of the CWF record to avoid application of the Part B deductible.  The A/B MACs (A) include in the financial data portion of the PS&R record, revenue code, HCPCS code, units, charges, and rate (fee schedule amount).  The PS&R system will include screening mammographies on a separate report from cost -based payments.  See the PS&R guidelines for specific information.