Screening and Diagnostic Mammography & 3D Tomosynthesis

Reimbursement Policy:
Screening and Diagnostic Mammography & 3D Tomosynthesis

Effective Date:
April 15, 2017

Purpose:
Provide guidelines for the processing of claims for multiple mammograms, CAD and Digital Breast Tomosynthesis (DBT) to align with recent changes to CMS’ position on screening and diagnostic mammograms and to define what a mammographic episode is. This policy applies to professional and institutional providers.

Scope:
All products are included, except

  • MediGap
  • Horizon NJ Health plans [i.e., Medicaid Managed Care, NJ FamilyCare, Managed Long-Term Services & Supports (MLTSS) and Horizon NJ TotalCare (HMO SNP)]
  • COB
  • No-Fault
  • BlueCard Home
  • FEP

All Insured and Administrative Services Only (ASO/ASC) accounts are included in Mammogram Screening and Diagnostic Services. All Insured plans are included in DBT services. All Administrative Services (ASO/ASC) groups that opt-in to the NJ Breast Cancer Screening Mandate are included in DBT services.

Definitions:
Mammographic Episode: DBTs will be allowed only once per mammographic episode in conjunction with either a screening or diagnostic mammogram. The majority of the episodes will occur once per year during the annual screening examination. There may be a smaller number of women who are scheduled to have a short-term follow up for a probably benign finding, BIRADS Category 3, and will have another examination in 6 months. DBTs may be appropriately used during those short-term follow up examinations.

Policy:
Mammography Screening and Diagnostic Services

When a screening and diagnostic mammography, CAD and DBT are performed on the member and the same date of service, the provider must report on findings for the initial and the separate session. The report(s) must demonstrate that the professional interpretation of the screening study led to the performance of a separate and second diagnostic procedure with direct physician supervision.

Claims submission for these procedures must include:

  • GG modifier on the diagnostic procedure code charge line, and
  • 59 , XE, or XU modifier on the screening procedure code charge line to reimburse both mammography claim procedures

Mammography Screening and Diagnostic procedure codes:

  • Screening codes: 77057, 77052, 77063, 77067, G0202
  • Diagnostic codes: 77055, 77056, 77051, 77061, 77062, 77065 (AMA eff. 1/1/2017), 77066, G0204, G0206, G0279

Procedure:
When performed on the same patient on the same date of service:

  • Both the mammography screening and diagnostic services shall be reimbursed when a GG modifier is appropriately appended to the diagnostic procedure code and a 59, XE or XU modifier is appropriately appended to the screening procedure code.

    The GG modifier will indicate a separate session for reimbursement of both services.
     
  • A DBT billed within six (6) months of a screening/diagnostic service will deny, and anything billed after six (6) months will be reimbursed. In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
12/14/2016: Policy Approved

Policy 102_v1.0_02142017