ACR Radiology Coding Source™ for January-February 2014 Q and A

A: Bundled codes were not structured to be reported by more than one physician. In 2014 the breast biopsy procedures are to be reported with only a single CPT code now that the surgery, radiological supervision and interpretation, specimen and clip placement codes are bundled into the new codes. Therefore, only a single provider (National Provider Identifier) can be reported on the CMS-1500 claim form and submitted to the carrier. Per the claim form instructions, the physician submitting the 1500 form certifies that he or she performed the entire service. 

 

If more than one physician submits a bill for the same service, the first claim into the payer is the one that is reimbursed and the second claim is usually denied. 

 

If a radiologist or radiology practice is approached to participate in an arrangement whereby the surgeon does the breast biopsy and the radiologist provides the interpretation, documentation of the arrangement, as well as advice by corporate legal counsel and a malpractice insurer, is critical to ensure the billing arrangement complies with federal and applicable state laws. 

 

A: As previously noted on the ACR Economics & Health Policy eNews page*, the Centers for Medicare and Medicaid Services (CMS) posted a November 6 FAQ stating that breast tomosynthesis produces direct digital images and, therefore, is appropriately reported using one of the three existing HCPCS codes that describe digital mammography services. They state breast tomosynthesis, and all other types of digital mammography, are described using G0202, G0204, and G0206.

 

The date practices were notified by their Medicare Administrative Contractor (MAC) is the effective date. We assume that all physicians have now received notice from Medicare contractors indicating they should ONLY report one of the G020X mammography codes when breast tomosynthesis is furnished. 

 

Radiology practices do not need to go back and refund breast tomosynthesis payments prior to the CMS notification. Prior to the posting of the CMS FAQ and its communication to physicians, a decision on coverage and payment was reached by payers, including Medicare contractors, since miscellaneous codes generally require manual adjudication. 

 

Medicare issues an FAQ as the fastest way to get information out to MACs and providers. As Medicare has published this, MACs should be following, and you must bill Medicare according to that guideline. 

 

The ACR strongly disagrees with the CMS recommendation to report only a digital mammography code. The digital mammography codes do not accurately describe the procedure performed or take into consideration the additional work and associated practice expense involved with breast tomosynthesis. Coverage varies from payer to payer based on contracts. As long as your third party payers maintain it is as a non-covered service you can continue to bill the patient. For example, a few payers cover CT colonography while others don't (including Medicare) so some patients have a screening colonography by CT while most patients have conventional colonoscopy since that is what is covered. 

 

Note that the ACR, American Roentgen Ray Society, and Radiological Society of North America proposed the designation of specific CPT codes for breast tomosynthesis at the American Medical Association’s February 2014 CPT Editorial Panel meeting in Phoenix. If approved by the panel, breast tomosynthesis codes will be available for use by the 2015 CPT code cycle. 

A: When a breast biopsy is performed under ultrasound guidance (19083), and the post-procedure mammogram is done in a digital room (G0206), it is appropriate to bill separately for both, the ultrasound-guided biopsy and the digital post-procedure mammogram as different modalities were used for the biopsy guidance and the post-procedural film. 

 

The wording in the 2014 National Correct Coding Initiative (NCCI) narrative now allows the coding of the post-procedure mammogram when a different modality is used for the breast biopsy.as noted in the following: 

 

If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with mammographic guidance (e.g., 19281, 19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.