December 31, 2015

CMS Reverts to a Bilateral Indicator 1 for Breast Ultrasound

The Centers for Medicare & Medicaid Services (CMS) has rescinded Transmittal 3364, dated September 29, 2015 and replaced with Transmittal 3407, dated November 18, 2015 to update the list of revisions to the “Quarterly update to the Medicare Physician Fee Schedule Database (October CY 2015 Update).” As noted in the associated MLN Matters MM9266, Document History, On November 25, the “What You Need to Know” section listing RVU changes was revised to remove several codes (76641, 76641-TC, 76641-26, 76642, 76642-TC, 76642-26) that had been listed with bilateral surgery indicator changes.

The listing of the breast ultrasound codes in Transmittal 3364 with the assignment of a bilateral indicator of “3” [The usual payment adjustment for bilateral procedures does not apply] was in error. Therefore, CMS immediately corrected the error by issuing Transmittal 3407. The assignment of a bilateral modifier indicator of “1” [150% payment adjustment for bilateral procedures applies] was discussed in the CY2015 Medicare Physician Fee Schedule Final Rule (p. 67666, Federal Register, Vol. 79, No. 219 / Thursday, November 13, 2014 / Rules and Regulations), which stated:

One difference between the predecessor code [76645] and the new ones [76641, 76642] is that while the predecessor code was used to report unilateral or bilateral breast ultrasounds, the new codes are unilateral ones. To appropriately adjust payment when bilateral procedures are furnished under the PFS, payments are adjusted to 150 percent of the unilateral payment when a service has a bilateral payment indicator assigned. We are assigning a bilateral payment indicator to these codes.

Radiology practices are advised to contact their local Medicare Administrative Contractors on how to handle any overpayments made.