Payment for Screening Mammography Services Provided On and After January 1, 2002 (Rev. 1070, 01-02-07)

by  Jared Staheli
June 25th, 2015

The payment limitation methodology does not apply to claims with dates of service on or after January 1, 2002.

FI Claims

For claims with dates of service on or after January 1, 2002, §104 of the Benefits Improvement and Protection Act (BIPA) 2000, provides for payment of screening mammography under the Medicare physician fee schedule (MPFS) when furnished in hospitals, skilled nursing facilities (SNFs), and CAHs not electing the optional method of payment for outpatient services. However, payment under the physician fee schedule is not applicable to hospitals subject to the Outpatient Prospective Payment System (OPPS) until April 1, 2002.

The payment for code 77057* (76092*) is equal to the lower of:

• The actual charge or

• Locality specific technical component payment amount under the MPFS.

Program payment for the service is 80 percent of the lower amount and coinsurance is 20 percent. Part B deductible does not apply. This is a final payment.

FIs use the benefit-pricing file provided by CMS to pay mammography codes.

Payment for the add-on code 76085 is made under the Medicare Physician Fee Schedule. Deductible does not apply, however, coinsurance is applicable.

*For claims with dates of service prior to January 1, 2007, providers report CPT code 76092. For claims with dates of service January 1, 2007 and later, providers report CPT code 77057.

Carrier Claims

Physicians and suppliers are paid by the carrier for all mammography tests (including screening mammography) under the MPFS. Separate prices for the technical component, the professional component and the global service are included on the MPFS.

The Medicare allowed charge is the lower of:

• The actual charge, or

• The MPFS amount for the service billed.

The Medicare payment for the service is 80 percent of the allowed charge. Coinsurance is 20 percent of the lower of the actual charge or the MPFS amount. Part B deductible is waived and does not apply to screening mammography.

As with other MPFS services, the nonparticipating provider reduction and the limiting charge provisions apply to all mammography tests (including screening mammography).

References:

• Pub 100-04 Medicare Claims Processing Manual - Chapter 18