Screening Mammography Benefit
In 1998 CMS began including annual screening mammography as a covered benefit under Medicare Part B.

Coding
The HCPCS codes for screening mammography and their corresponding Medicare reimbursement rates (participating providers) are as follows:

76083: Computer aided detection (computer algorithm analysis of digital image date for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images, screening mammography (List separately in addition to code for primary procedure) Effective January 1, 2004
Reimbursement: $17.84 ($3.29 for the professional component and $14.55 for the technical component)

76092: Screening mammography, bilateral (two view film study of each breast)
Reimbursement: $79.33 ($35.33 for the professional component and $44.00 for the technical component)

G0202: Screening mammography, producing direct digital image, bilateral, all views Effective April 1, 2004
Reimbursement: $123.66 ($35.33 for the professional component and $88.33 for the technical component)

Patient Costs
The Medicare Part B deductible does not apply to screening mammography; however, the patient is still required to pay a 20 percent copayment, which usually amounts to $15 to $25.

Guidelines
While guidelines for women under age 50 vary among organizations, there is consensus that women age 50 and older should have an annual mammogram.

For more information, go to http://www.guidelines.gov/ and search on "screening mammography."

Mammography Quality Standards Act and Mammography Facilities
The Food and Drug Administration oversees the Mammography Quality Standards Act, which regulates the operations of mammography facilities. For information on this act and a list of FDA-certified mammography facilities in New Mexico, see www.fda.gov/cdrh/mammography.

CMS National Measurement Specifications
The Centers for Medicare & Medicaid Services (CMS) provides national measurement specifications, which provide additional detail on CMS's diabetes indicators and Current Procedural Terminology (CPT) codes. Click here to download.

Frequently Asked Questions

What time period between screening mammograms ensures Medicare reimbursement?

Eleven months must have elapsed following the last mammogram. This is counted by calendar months and not by days. For example, if a woman has a screening mammogram paid for by Medicare in November 2005, begin counting the 11 months as of December 2005. The woman is then eligible for another mammogram after the 11th month has elapsed, so she will be eligible after October 31 of 2006: or in November of 2006.

How can a patient's eligibility for a screening mammogram be checked?

Patients can call the New Mexico Part B carrier's office at (505) 872-2551 to check eligibility status for screening mammography. Practitioners also may call the same number with the patient's permission. It is important to have the patient's name, HIC number and the state where the patient believes the last screening mammogram was performed.

What protection does a practitioner have if the patient cannot recall if she is eligible for a screening mammogram?

In cases where the health care practitioner cannot determine if a patient is eligible for services, a waiver can be issued that the patient must sign. If the practitioner provides the service and is denied due to ineligibility, the patient then assumes responsibility for payment.

If a woman presents for a screening mammogram and it is determined that a diagnostic mammogram is then required, can the radiology facility bill for a diagnostic mammogram performed on the same day?

A modification can be made to change the billing from a screening mammogram to a diagnostic and the higher reimbursement for the diagnostic mammogram will be paid. Congress sets these rules and reimbursement rates. Medicare sees a diagnostic mammogram as additional views to a screening mammogram.

Is a written order required for a screening mammogram?

CMS does not require a written order; however, statutes in New Mexico regarding radiology services, the interpretation that may be made of the statutes, and the requirements of the Mammography Quality Standards Act may create the need for a written order, depending upon the radiology facility.

To learn more about participating with NMMRA in quality improvement projects on mammography, contact Patricia Montoya, RN, MPA, quality improvement manager, at (505) 998-9735.