by Jared Staheli
June 26th, 2015
Contractors use the weekly-updated file to verify that the billing facility is certified by the FDA to perform mammography services, and has the appropriate certification to perform the type of mammogram billed (film and/or digital). Carriers/B MACs match the FDA assigned, 6-digit mammography certification number on the claim to the FDA mammography certification number appearing on the file for the billing facility. Carriers/B MACs complete the following activities in processing mammography claims:
• If the claim does not contain the facility’s 6-digit certification number, or if a 6- digit certification number is not reported in item 32 of the Form CMS-1500 for paper claims, or in the 2400 loop (REF 02 segment, where 01=EW segment) of the ASC X12N 837 professional claim format, version 4010A1, for electronic claims, then carriers/B MACs return the claim as unprocessable.
• If the claim contains a 6-digit certification number that is reported in the proper field or segment (as specified in the previous bullet) but such number does not correspond to the number specified in the MQSA file for the facility, then carriers/B MACs deny the claim.
• When a film mammography HCPCS code is on a claim, the claim is checked for a “1” film indicator.
• If a film mammography HCPCS code comes in on a claim and the facility is certified for film mammography, the claim is paid if all other relevant Medicare criteria are met.
• If a film mammography HCPCS code is on a claim and the facility is certified for digital mammography only, the claim is denied.
• When a digital mammography HCPCS code is on a claim, the claim is checked for “2” digital indicator.
• If a digital mammography HCPCS code is on a claim and the facility is certified for digital mammography, the claim is paid if all other relevant Medicare criteria are met.
• If a digital mammography HCPCS code is on a claim and the facility is certified for film mammography only, the claim is denied.
• Process the claim to the point of payment based on the information provided on the claim and in carrier claims history.
• Identify the claim as a screening mammography claim by the CPT-4 code listed in field 24D and the diagnosis code(s) listed in field 21 of Form CMS-1500.
• Assign physician specialty code 45 to facilities that are certified to perform only screening mammography.
• Ensure that entities that bill globally for screening mammography contain a blank in modifier modifier position #1.
• Ensure that entities that bill for the technical component use only HCPCS modifier “-TC.”
• Ensure that physicians who bill the professional component separately use HCPCS modifier “-26.”
• Send the mammography modifier to CWF in the first modifier position on the claim. If more than one modifier is necessary, e.g., if the service was performed in a rural Health Manpower Shortage Area (HMSA) facility, instruct providers to bill the mammography modifier in modifier position 1 and the rural (or other) modifier in modifier position 2.
• Ensure all those who are qualified include the 6-digit FDA-assigned certification number of the screening center in field 32 of Form CMS-1500 and in the REF02 segment (where 01 = EW segment) of the 2400 loop for the ASC X12N 837 professional claim format, version 4010A1. Carriers/B MACs retain this number in their provider files.
• Waive Part B deductible and apply coinsurance for a screening mammography.
• Add diagnosis code V76.12 if a claim comes in for screening mammography without a diagnosis and the carrier file data shows this is appropriate. If there are other diagnoses on the claim, but not code V76.12, add it. (Do not change or overlay code V76.12 but ADD it.) At a minimum, edit for age, frequency, and place of service (POS).
• After May 23, 2008, accept the screening mammography facility’s NPI number in place of the attending/referring physician NPI number for self-referred mammography claims.
• When a mammography claim contains services subject to the anti-markup payment limitation and the service was acquired from another billing jurisdiction, the provider must submit their own NPI with the name, address, and zip code of the performing physician/supplier.
• Refer to Pub. 100-04, chapter 1, section 10.1.1.1., for claims processing instructions for payment jurisdiction on Form CMS-1500 and electronic form ANSI X12 837P. NOTE: Beginning October 1, 2003, carriers/B MACs are no longer permitted to add the ICD-9 code for a screening mammography when the screening mammography claim has no diagnosis code. Screening mammography claims with no diagnosis code must be returned as unprocessable for assigned claims. For unassigned claims, deny the claim.
Carrier Provider Education
• Educate providers that when a screening mammography turns to a diagnostic mammography on the same day for the same beneficiary, add the “-GG” modifier to the diagnostic code and bill both codes on the same claim. Both services are reimbursable by Medicare.
• Educate providers that they cannot bill an add-on code without also billing for the appropriate mammography code. If just the add-on code is billed, the service will be denied. Both the add-on code and the appropriate mammography code should be on the same claim.
• Educate providers to submit their own NPI in place of an attending/referring physician NPI in cases where screening mammography services are self-referred.