Revisions to 2015 Medicare Physician Fee Schedule (MPFS) payment policies include a surprising billing guideline from the U.S. Centers for Medicare and Medicaid Services (CMS) related to digital breast tomosynthesis (DBT). Agency representatives announced this change to the American College of Radiology (ACR) during a December 14, 2014, phone call, and it was so surprising that the ACR staff person requested the directive be put in writing "because of concern that this advice would expose our members to allegations of fraud and abuse."
Specifically, CMS indicated that providers should report one of the following level II codes for diagnostic mammography plus code G0279 (diagnostic digital breast tomosynthesis, unilateral or bilateral) -- even if it wasn't performed:
- G0204: Diagnostic mammography, producing direct 2D digital image, bilateral, all views
- G0206: Diagnostic mammography, producing direct 2D digital image, unilateral, all views
Straight from the source
In the 2015 MPFS correction notice, CMS stated that on page 67668 (first column) of the final rule it had inadvertently omitted the phrase "whether or not a 2D mammography is furnished." The section in which this occurs now reads as follows:
Those furnishing diagnostic mammography using tomosynthesis will continue to report G0204 and G0206 as appropriate. In addition, we are creating a new code, G0279 ... as an add-on code that should be reported in addition to the relevant 2D diagnostic mammography G-code to recognize the additional resources involved in furnishing diagnostic breast tomosynthesis whether or not a 2D mammography is furnished.
Initially, ACR advised radiology providers to use an unlisted code when DBT (without full-field digital mammography) was performed on a Medicare patient because G0279 is an add-on code and must be used in addition to a base code. However, CMS asked ACR to recommend instead that providers bill with G0279 and either G0204 or G0206, as appropriate.
In response, ACR requested a conference call with CMS because of "its belief that the reporting of a procedure code on a claim for a service that was not performed goes against every principle of coding," as it explains in its website announcement. "The current policy could become a huge compliance issue leaving radiology practices potentially vulnerable to Office of Inspector General and Recovery Audit Contractor audits."
If ever questioned or audited about this reporting practice, ACR advises radiology providers to refer to the March 19, 2015, MPFS correction notice from CMS.
Future payment TBD
In the 2015 MPFS final rule, CMS stated its intent to include the digital mammography codes in the list of potentially misvalued codes, which currently includes tomosynthesis as well as 2D mammography.
The agency said it will wait to value the new diagnostic mammography tomosynthesis codes until it has received recommendations from the American Medical Association's (AMA) Specialty Society Relative Value Scale Update Committee (RUC). For the interim, it assigned a PFS indicator of "I'' to the following codes:
- 77061: Digital breast tomosynthesis; unilateral
- 77062: Digital breast tomosynthesis; bilateral
Donna Richmond is a senior healthcare consultant, clinical consulting services, for Panacea Healthcare Solutions. In addition to her coding hotline responsibilities for Panacea, she performs a variety of radiology and cardiology audits and contributes to several webcasts and publications, including MedLearn Publishing's new Basics of Interventional Radiology Coding book.
The comments and observations expressed herein are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.
