February 10, 2017

ACR Works to Preserve Fair Mammography Payments

The American College of Radiology’s (ACR) ongoing efforts to assure appropriate Medicare reimbursement rates for mammography have had a positive effect on revisions to federal payment policies in 2017 for these essential diagnostic imaging services.

In November, the ACR notified members about changes to the coding structure and potentially to future payment rates for mammography services. The Centers for Medicare and Medicaid Services (CMS) opted not to use the new Current Procedural Terminology (CPT®) 2017 codes that bundle computer-aided detection (CAD) with mammography services. Instead, CMS revised the Healthcare Common Procedure Coding System (HCPCS) Level II “G” code descriptors to be the same as the CPT code descriptors, as noted in the Medicare Physician Fee Schedule Final Rule. For 2017, codes G0202, G0204 and G0206 describe mammography with CAD when performed for Medicare beneficiaries. Radiology practices are advised to check with their third-party payers to determine if they will use the CPT or HCPCS Level II “G” codes in 2017.

With regard to reimbursement, CMS granted a slight increase in 2017 for the professional component work relative value unit (RVU) as recommended by the ACR and deciding against updating the technical component RVUs based on direct inputs recommended by Relative Value Scale Update Committee (RUC) and used in the Agency’s practice expense (PE) formula. An affirmative decision by CMS on the updates would have yielded a 50 percent cut in 2017 payment rates. CMS noted in the final rule that it intends to re-visit this issue in 2018, however.

The ACR has studied the reasons for the potential year-to-year reimbursement cuts to the technical component of mammography services. Coding and payments for mammography services have been relatively stable compared to other imaging procedures since the early 2000s, when the Benefits Improvement and Protection Act of 2000 (BIPA) mandated coverage and payment of full field digital mammography (FFDM) services under Medicare. BIPA mandated that Medicare’s technical component payment for FFDM must be one and a half times higher than the technical component of the value of the film-based codes.

The creation of new CPT codes that bundled digital mammography with CAD subsequently led to the valuation of the codes using standard CMS methodology, with recommendations from the RUC, as opposed to code valuations based on higher BIPA payment rates. Separately, updates to the broader PE methodology, such as this year’s update to radiology’s practice expense per hour (PE/Hr) have affected valuations. CMS recognized in the 2017 final rule that a 50 percent technical component reimbursement rate cut could potentially disrupt patient access. The ACR agreed and thanked CMS for maintaining the current reimbursement rates.

The College is working to set up a meeting with CMS staff to further discuss this issue as the Agency develops the 2018 Medicare Physician Fee Schedule proposed rule. We will keep ACR members apprised as we consider our options for helping maintain patient access to mammography services.