September 30, 2016

ACR Inquiry Spurs Remedy for Mammo Payment Denials

In response to an American College of Radiology (ACR) inquiry, the Food and Drug Administration (FDA) and Centers for Medicare & Medicaid Services (CMS) have jointly identified the source and probable solution to an administrative problem that recently led CMS to inappropriately deny mammography payment claims for imaging services from WPS, a Medicare administrative contractor.

The ACR contacted the FDA and CMS after receiving complaints from radiology practices this year about unjustified denials from CMS for a number of reimbursement claims for mammography.

The FDA and CMS determined the updated FDA file format used to convey information to CMS on provider eligibility for reporting mammography services was at the root of the problem. The FDA asked CMS to stop using the new FDA file until a fix is made (or at least until the effective date that is causing the problem) and revert to the use of the old file that CMS continues to receive from the FDA. WPS has instructed its practices to resubmit their claims.

In addition, the ACR was notified that some practices’ claims are being denied because 2016 CPT® codes 77055, 77056, 77057 are being used to describe digital mammography. Although the mammography CPT code descriptors were revised in 2016 to describe either film or digital mammography, CMS Medicare administrative contractors continue to require the reporting of the Healthcare Common Procedure Coding System (HCPCS) Level II “G” codes G0202, G0204 and G0206. Therefore, radiology practices should submit Medicare beneficiary claims for digital mammograms using the G codes until otherwise instructed by CMS. In 2016, codes 77055, 77056 and 77057 may be reported for Medicare beneficiaries for film mammography.

See the Medicare Claims Processing Manual, Chapter 18, Section 20 for specific guidelines on the submission of mammography claims.

The September/October2016 ACR Radiology Coding Source (to be posted the end of October) and the 2016 Fall Bulletin of the AMA/ACR’s Clinical Examples in Radiology will provide a list of all 2017 coding updates. New codes have been established that bundle computer-aided detection (CAD) with mammography. The current CAD and mammography codes 77051, 77052, 77055, 77056, and 77057 will be deleted in 2017. It is anticipated that the HCPCS Level II G codes G0202, G0204 and G0206 also will be deleted, as the new mammography codes refer to either digital or analog procedures.

For more information, contact Diane Hayek, ACR director of billing and coding.