Medicare Guidelines - Screening and Diagnostic Mammography CPT Code (77067, 77066 & 77065)
Screening and Diagnostic Mammography CPT Code:
Reimbursement Guidelines for Screening Mammography Code:
Reimbursement Guidelines for Diagnostic Mammography Code:
- Effective 01/01/2018, Screening mammography CPT code G0202 & Diagnostic mammography CPT codes G0204, and G0206 were deleted.
- CPT codes G0202, G0204 & G0206 were replaced with 77067, 77066 & 77065 respectively.
- It is necessary to bill Screening digital breast tomosynthesis CPT 77063 in conjunction with Screening mammography CPT 77067, Diagnostic digital breast tomosynthesis bilateral CPT 77062 in conjunction with Diagnostic mammography CPT 77066 & Diagnostic digital breast tomosynthesis unilateral CPT 77061 in conjunction with Diagnostic mammography CPT 77065 to get these mammography CPTs paid.
- Effective 01/01/2018, CPT G0279 must be billed with CPT 77065 & 77066 for reimbursement.
Reimbursement Guidelines for Screening Mammography Code:
- Payment may not be made for screening mammography performed on a woman under age 35.
- Payment may be made for only one screening mammography performed on a woman over age 34 but under age 40.
- For an asymptomatic woman over age 39, payment may be made for screening mammography performed after at least 11 months have passed following the month in which the last screening mammography was performed.
Reimbursement Guidelines for Diagnostic Mammography Code:
- A patient has distinct signs and symptoms for which a mammogram is indicated.
- A patient has a history of breast cancer.
- A patient is asymptomatic but on the basis of the patient's history and other factors the physician considers significant, the physician's judgment is that a mammogram is appropriate.
Hi Teams
ReplyDeleteAuths for IMRT and IGRT CPT codes for radiation are approved by Evicore on behalf payers like Cigna & BCBS in terms of fractions. These payers denied the claims as approved auth is inconsistent with service billed. When followed up payers, rep stated that this auth was approved only for cpt code 77399, which is an unlisted code. When the auth was initiated, our auth team included all radiation codes like 77017,77470,G6015, G6002, etc. But Evicore approved the auth as 45 Fractions of IMRT & IGRT but did not mentioned the specific CPTs and it was forwarded to payers as 77399 approved for 1 Unit only. Is there a way by which we upgrade the required CPTs with Evicore. Some senior reps of Claims Dept suggested to file an appeal with auth approval letter and medical records becoz 77399 is a generic code that can represent those CPTs of the denied claim depending on the Dx. Please suggest any way forward. And is there anyone working on Radiation AR and facing the same scenario if so how do you resolve this issue.
You have two options:
Delete1. Contact Evicore and request an upgrade of the existing authorization to the appropriate CPT codes. However, in most cases Evicore does not approve these upgrade requests.
2. Submit an appeal with the Evicore authorization approval letter, medical records, and an explanation stating that Evicore approved the treatment by fractions but did not assign specific CPT codes. This option has a much higher chance of success.
To avoid this issue in the future, please ask to include all cpts in the authorization while submitting request for authorization.