Attachment A - MBCCP Covered Services and CPT Codes.docx

Massachusetts Breast and Cervical Cancer Program (MBCCP) Attachment A: Covered Services and Allowable CPT Codes

Listed below are allowable procedures and the corresponding CPT codes for use in the Massachusetts Breast and Cervical Cancer Program (MBCCP). CPT codes for the MBCCP are set by the Centers for Disease Control and Prevention National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and are updated annually. These general conditions apply:

· Payment of medical services is reimbursed on a fee-for-service basis using Medicare Urban Rates for selected Current Procedural Terminology (CPT) codes.

· In compliance with CDC requirements, reimbursement rates cannot exceed the Medicare Urban rates (locality 01) which usually, but not always, exceed the suburban rates. In instances where a Medicare rate is not applicable, a regional average is used. MDPH reserves the right to modify reimbursement rates and add or eliminate service codes, at any time based on changes in Medicare reimbursement, state or federal mandates or the availability of funds.

· If a patient has Health Safety Net, only the Professional Component of a service is covered by the MBCCP.

· Reimbursement for treatment services or medications is not allowed.

· The MA Department of Public Health (MDPH) is the payor of last resort for all covered services.

· MDPH cannot pay for tests or services provided to a patient prior to their member enrollment date. The enrollment date is the date the patient consented to participate in the program.

· Any questions regarding coverage for MBCCP services should be directed to MDPH PRIOR to the service being performed to determine if the services will be reimbursed by the program.

Office Visits (Evaluation and Management)

99395

Co-pays and Deductibles

Breast Cancer Screening and Diagnostic Procedures

Breast Screening Mammography

77067

Screening mammography, bilateral (two view film study of each breast)

Breast Diagnostic Mammography

77065

Diagnostic Mammography; unilateral, includes CAD

77066

Diagnostic mammography, bilateral, Includes CAD

76098

Radiological examination, surgical specimen

77063

G0279

Tomosynthesis, Mammogram

Breast Diagnostic Imaging

Breast Biopsies

Breast Diagnostic Pathology & Cytopathology

Anesthesia/Miscellaneous

FACFEE

Facility Fee for use of the facility, personnel & its equipment for procedures provided within a hospital or other Ambulatory Surgical Center. This fee is separate from the doctor's professional fee and anesthesia services.

Cervical Screening and Diagnostic Procedures

Cervical Screening Cytopathology

End Note

Cervical Diagnostic

Cervical Pathology

Conscious Sedation Anesthesia

Other COVID Pathology

87426

COVID-19 infectious agent detection by nuclei acid DNA or RNA; amplified probe technique

87635

COVID-19 infectious agent antigen detection by immunoassay technique; qualitative or semiquantitative

Other

Procedures Specifically Not Allowed/Covered by the MBCCP

Any

Treatment of breast carcinoma in situ, breast cancer, cervical intraepithelial neoplasia and cervical cancer.

77061

Breast tomosynthesis, unilateral

77062

Breast tomosynthesis, bilateral

87623

Human papillomavirus, low-risk types

End Notes

All consultations should be billed through the standard “new patient” office visit CPT codes 99201–99205. Consultations billed as 99204 or 99205 must meet the criteria for these codes. These codes (99204–99205) are typically not appropriate for NBCCEDP screening visits. However, they may be used when provider spends extra time to do a detailed risk assessment.

The 9938X codes shall be reimbursed at or below the 99203 rate, and 9939X codes shall be reimbursed at or below the 99213 rate. The type and duration of office visits should be appropriate to the level of care needed to accomplish screening and diagnostic follow-up within the NBCCEDP. While some programs may need to use 993XX-series codes, Preventive Medicine Evaluation visits are not covered by Medicare and not appropriate for the NBCCEDP

List separately in addition to code for primary procedure 77067.

List separately in addition to 77065 or 77066.

Breast MRI can be reimbursed by the NBCCEDP in conjunction with a mammogram when a client has a BRCA gene mutation, a first-degree relative who is a BRCA carrier, or a lifetime risk of 20% or greater as defined by risk assessment models, such as BRCAPRO, that depend largely on family history. Breast MRI also can be used to assess areas of concern on a mammogram, or to evaluate a client with a history of breast cancer after completing treatment. Breast MRI should never be done alone as a breast cancer screening tool. Breast MRI cannot be reimbursed for by the NBCCEDP to assess the extent of disease in a woman who has just been newly diagnosed with breast cancer in order to determine treatment plan.

Codes 19081–19086 are to be used for breast biopsies that include image guidance, placement of a localization device, and imaging of specimen. They should not be used in conjunction with 19281–19288.

Codes 19281–19288 are for image guidance placement of a localization device without image-guided biopsy. These codes should not be used in conjunction with 19081–19086.

For CPT 10011 use the reimbursement rate for CPT code 10009. For CPT 10012 use the reimbursement rate for CPT code 10010.

Example: If procedure is 50 minutes, code 99156 + (99157 x 2). No separate charge allowed if procedure <10 minutes.

These procedures have not been approved for coverage by Medicare.

MBCCP providers must comply with the requirements set forth by the Centers for Medicare & Medicaid Services before providing and invoicing for this service.

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