Coding/Billing Information

HCPCS and Diagnosis Codes, along with modifiers used for Mammography Services, are located in the Downloads section below.

Basic Coverage Rules

The law, Mammography Quality Standards Act (MQSA), requires the Secretary to ensure that all facilities that provide mammography services meet national quality standards. Effective October 1, 1994, all facilities providing screening and diagnostic mammography services (except VA) must have a certificate issued by the Food and Drug Administration (FDA) in order to be reimbursed by Medicare.

The Medicare law and regulations provides for coverage of screening mammograms for women without signs or symptoms of breast disease for the purpose of early detection of breast cancer, including a physician's interpretation of the results of the procedure.

Coverage applies as follows:
Under age 35 = No payment is allowed for screening
Age 35 to 39 = (Baseline) Pay for only one screening mammography performed on a woman between her 35th and 40th birthday
Over age 39 (i.e: 40 and over) = Annual (11 full months have elapsed following the month of last screening).
Part B deductible is waived per BBA however co-insurance applies.

A doctor's prescription or referral is not necessary for screening mammograms to be covered.

A diagnostic mammogram is a covered radiological procedure that is furnished to a man or woman with signs or symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and it includes a physician's interpretation of the results of the procedure. Unlike the screening mammogram, the diagnostic procedure does require a doctor's prescription or referral in order for coverage to be available.

All Carrier Payments are paid under the Medicare Physician Fee Schedule (MPFS).

FI payments are made under the MPFS, OPPS, and lower of the actual charge. Please refer to sections 20.3.2.1 and 20.3.2.4 in the new Internet Only manual for more information on payment methodology for claims paid under the FI. Note: As of January 1, 2005, all payments will be made under the MPFS.

Computer Aided Detection (CAD) codes are not to be billed alone. They must be billed with the primary HCPCS code.

Downloads
HCPCS and Diagnosis Codes [PDF, 84KB] Modifiers [PDF, 58KB] Billing Contacts [PDF, 33KB]
Related Links Inside CMS
Medicare Learning Network CMS Transmittals HCPCS General Information ICD-9 Provider & Diagnostic Codes
Related Links Outside CMS
Payment and Standards for Screening Mammography List of FDA-Certified Mammography Centers US Food and Drug Administration - CDRH/Mammography

Page Last Modified: 03/15/2006 2:40:00 PM
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