evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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  The 14X type of bill is no longer applicable.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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.  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:
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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).
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)  B3-4601.4, A3- 3660.10.I, SNF -537.2.G
(Medicare Claims Processing Manual)
20.8 - Beneficiary and Provider Notices  (Rev. 1, 10- 01-03)  B3-4601.4, A3- 3660.10.I, SNF -537.2.G   20.8.1 - MSN Messages (Rev. 3961, Issued: 02- 02- 18, Effective: 01 -01- 18, Implementation: 07- 02-18)  B3-4601.4, A3- 3660.10.I  The following messages are used on the MSN. If the claim is denied because the beneficiary is under 35 years of age, use the following MSN:  MSN 18.3:   Screening mammography is not covered for women under 35 years of age.  The Spanish version of this MSN message should read:  Las pruebas de mamografa para mujeres menores de 35 aos no estn cubiertas.  If the claim is denied for a woman 35- 39 because she has previously received this examination, use the following MSN:  MSN 18.6:  A screening mammography is covered only once for women age 35- 39.
(Medicare Claims Processing Manual)
The Spanish version of this MSN message should read:  Una mamografa de cernimiento es cubierta una vez solamente para mujeres entre las edades de 35 -39. If the claim is denied because the period of time between screenings for the woman based on age has not passed, use the following MSN:  MSN 18.4:  This service is being denied because it has not been 12 months since your last examination of this kind.  (NOTE: Insert appropriate number of months.)  The Spanish version of this MSN message should read:  Este servicio se deneg debido a que no han transcurrido 12 meses desde su ltimo examen de este tipo.  If the claim is denied because the provider is not certified to perform a mammography, use the following MSN:  MSN 16.2:  This service cannot be paid when provided in this location/facility. The Spanish version of this MSN message should read:  Este servicio no se puede pagar cuando es suministrado en este sitio/facilidad. In addition to the above denial messages, the A/B MAC (A) or (B) may add the following:  MSN 18.12:   Screening mammograms are covered annually for women 40 years of age and older. The Spanish version of this MSN message should read:  El examen de mamografa de cernimiento se cubre una vez al ao para mujeres de 40 aos de edad o ms.  For A/B MACs (B) only:  For claims submitted with invalid or missing certification number, use the following MSN:  MSN 9.2:  This item or service was denied because information required to make payment was missing.  The Spanish version of this MSN message should read:  Este artculo o servicio fue denegado porque la informacin requerida para hacer el pago fue omitida.
(Medicare Claims Processing Manual)
20.8.2 - Remittance Advice Messages  (Rev. 3961, Issued: 02- 02- 18, Effective: 01 -01- 18, Implementation: 07- 02-18)  If the claim is denied because the beneficiary is under 35 years of age, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with C AQH CORE Business Scenario Three.   CARC: 6  RARC: M37    Group Code: CO   If the claim is denied for a woman 35- 39 because she has previously received this examination, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   CARC: 119  RARC: M89   Group Code: CO   If the claim is denied for a woman age 40 and above because she has previously received this examination within the past 12 months, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under t his policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   CARC: 119  RARC: M90  Group Code: CO    If the claim is denied because the provider that performed the screening is not certified to perform the type of mammography billed (film or digital) the contractor shall use the following remittance advice messages and associated codes when rejecting/deny ing claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   CARC: B7  RARC: N570    Group Code: CO  For claims that were submitted without the facilitys FDA -assigned certification number, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.   CARC: 16  RARC: MA128  Group Code: CO  For claims that were submitted with an invalid facility certification number, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant w ith CAQH CORE Business Scenario Two.   CARC: 16  RARC: MA128  Group Code: CO