Breast Imaging: Coding & Payment Guide 2019

Breast Imaging Coding and Payment Guide 2019 siemens-healthineers.us CPT©/HCPCS Code¹ Description Service Component Total RVU2 2018 National Medicare Rate² Mammography • HCPCS codes G0202, G0204 and G0206 were deleted for 2018 and replaced with CPT codes 77065-77067 to report diagnostic or screening mammography services. Use of computer-aided detection (CAD) is bundled into CPT codes 77065-77067, when performed. • Medicare pays for mammography services (including tomosynthesis) delivered in either office/freestanding centers or hospital outpatient departments using the physician fee schedule (PFS) rates. There are no separate rates published under the hospital outpatient prospective payment system (OPPS). Note: For film x-rays, Medicare requires that the FX modifier be appended to the CPT/HCPCS code. This results in a 20 percent payment reduction to the technical component (or technical component of the global service) for film x-rays. Use of mammography systems utilizing computed radiography/cassette-based imaging must be appended with the FY modifier and will be result in a 7 percent payment reduction to the technical component (or technical component of the global service). Check with your payer for any coding requirements and payment impacts for using film or computed radiography Screening mammography, bilateral (2-view Global Payment 3.88 $139.68 77067 study of each breast), including computer- Professional Component (26) 1.06 $38.16 aided detection (CAD) when performed Technical Component (TC) 2.82 $101.52 Diagnostic mammography, including Global Payment 4.80 $172.80 77066 computer-aided detection (CAD) when Professional Component (26) 1.39 $50.04 performed; bilateral Technical Component (TC) 3.41 $122.76 Diagnostic mammography, including Global Payment 3.79 $136.44 77065 computer-aided detection (CAD) when Professional Component (26) 1.12 $40.32 performed; unilateral Technical Component (TC) 2.67 $96.12 Tomosynthesis Breast tomosynthesis codes 77063 and G0279 are billed in conjunction with the appropriate screening or diagnostic mammography code (77065-77067). CPT codes 77061-77062 for diagnostic digital breast tomosynthesis are not utilized by Medicare. Check with your payer to confirm the code(s) accepted for to mosynthesis services. Screening digital breast tomosynthesis, Global Payment 1.56 $56.16 77063 bilateral (List separately in addition to code Professional Component (26) 0.85 $30.60 for primary procedure) Technical Component (TC) 0.71 $25.56 Diagnostic digital breast tomosynthesis, Global Payment 1.56 $56.16 G0279 unilateral or bilateral (list separately in Professional Component (26) 0.85 $30.60 addition to G0204 or G0206) Technical Component (TC) 0.71 $25.56 SIEMENS Healthineers CPT©/HCPCS Code¹ Description Service Component Total RVU2 2018 National Medicare Rate² Breast Ultrasound • CPT 76641 represents a complete ultrasound examination consisting of all four quadrants of the breast and the retroareolar region, including examination of the axilla if performed. CPT 76642 represents a focused ultrasound examination of one or more, but not all four quadrants, and includes examination of the axilla if performed. CPT 76641 and 76642 are unilateral ultrasound examinations. If breast ultrasound is performed bilaterally with either code, it should be billed using a bilateral payment modifier (i.e., 50, LT, RT), and will be paid at 150% of the unilateral payment. • Medicare pays for global, technical and professional components of breast ultrasound services delivered in the office/freestanding facility setting under the physician fee schedule (PFS) and technical services delivered in a hospital outpatient department under the hospital outpatient prospective payment system (OPPS). Check with your payer to confirm the code(s) accepted and payment policies for breast ultrasound services. Global Payment 3.06 $110.16 Ultrasound, breast, unilateral, real time Professional Component (26) 1.04 $37.44 76641 with image documentation, including axilla when performed; complete Technical Component (TC) 2.02 $72.72 Hospital payment (outpatient) APC 5522 $118.74 Global Payment 2.51 $90.36 Ultrasound, breast, unilateral, real time Professional Component (26) 0.97 $34.92 76642 with image documentation, including axilla when performed; limited Technical Component (TC) 1.54 $55.44 Hospital payment (outpatient) APC 5521 $62.11 ¹American Medical Association (AMA), 2018 Current Procedural Terminology (CPT), Professional Edition. CPT® is a registered trademark of the American Medical Association. CPT codes and descriptions only are copyright 2017 AMA. All rights reserved. The AMA assumes no liability for data contained herein. Applicable FARS/DFARS Restrictions Apply for Government Use. Centers for Medicare & Medicaid Services (CMS), 2018 Healthcare Common Procedure Coding System (HCPCS) codes, available at http://www.cms.gov/Medicare/Coding/ HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html. ²The 2018 physician relative value units (RVUs) are from the 2018 Medicare Physician Fee Schedule (PFS) Final Rule, Addendum B. The payment rates are calculated using the 2018 PFS conversion factor of $35.9996 and do not reflect payment cuts due to sequestration or other Medicare policies. Medicare physician payment for a given procedure in a given locality in 2018 should be available in the Medicare Physician Fee Schedule Look-up file accessible through the CMS website at http://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Any payment rates listed may be subject to change without notice. Actual payment to a physician or hospital will vary based on geographic location and may also differ based on policies and fee schedules outlined as terms in your health plan and/or payer contracts. Hospital outpatient rates and ambulatory payment classifications (APCs) are from the 2018 Medicare Hospital Outpatient Prospective Payment System (OPPS), Addendum B. PFS Retreived from: Retrieved from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/ PFS-Federal-Regulation-Notices-Items/CMS-1676-F.html; OPPS retreived from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1678-FC.html. ³CPT codes 76641 and 76642 have an OPPS status indicator of “Q1,” meaning that payment is packaged and not paid separately if billed on the same date of service as a CPT/HCPCS code assigned status indicator “S”, “T”, or “V”; otherwise payment is made through a separate APC payment. Siemens Healthineers provides this coding guide for informational purposes only. This guide is not an affirmative instruction as to which codes and modifiers to use for a particular service, supply, procedure or treatment. It is the provider’s responsibility to determine and submit the appropriate codes and modifiers for any service, supply, procedure or treatment rendered. Actual codes and/or modifiers used are at the sole discretion of the treating physician and/or facility. Contact your local payer for specific coding and coverage guidelines. Siemens Healthineers cannot guarantee medical benefit coverage or reimbursement with the codes listed in this guide. 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