Medicare payment for CPT 77051, 77052 & 77055

MEDICARE REIMBURSEMENT FOR MAMMOGRAPHY SERVICES

Table 1: 2009 Medicare Reimbursement for Mammography Procedures
(Reflects National Rates, Unadjusted For Locality)

Technology :  Computer-Aided Detection (CAD)


CPT/HCPCS Code : CPT 77051 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to
code for primary procedure) [Use 77051 in conjunction with 77055, 77056]

Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:

Technical                                                        $9.02
Professional                                                   $3.25
Global                                                             $12.26

CPT/HCPCS Code :CPT 77052 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to
code for primary procedure) [Use 77052 in conjunction with 77057]


Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                        $9.02
Professional                                                   $3.25
Global                                                             $12.26





Technology : Plain Film

CPT/HCPCS Code :  CPT 77055 Mammography; unilateral


Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                       $49.05
Professional                                                  $35.71
Total                                                               $84.76


CPT/HCPCS Code : CPT 77056 Mammography; bilateral (Use 77055, 77056 in conjunction with 77051 for CAD applied to diagnostic mammogram)


Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                       $63.12

Professional                                                  $44.36
Total                                                              $107.48


CPT/HCPCS Code :  CPT 77057 Screening mammography, bilateral (2-view film study of each breast) (Use 77057 in conjunction with 77052 for CAD applied to a screening mammogram


Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                       $45.80

Professional                                                  $35.71
Total                                                               $81.51




Technology : Digital

CPT/HCPCS Code :  HCPCS G0202 Screening mammography, producing direct digital image, bilateral, all views


Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                       $94.86

Professional                                                  $34.98
Total                                                               $129.84


CPT/HCPCS Code :  HCPCS G0204 Diagnostic mammography, producing direct digital image, bilateral, all views

Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                      $109.28

Professional                                                 $43.28
Total                                                             $152.56


CPT/HCPCS Code :  HCPCS G0206 Diagnostic mammography, producing direct digital image, unilateral, all views

Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                     $86.20

Professional                                                $34.98
Total                                                            $121.18


* Technical- is the facility payment
**Professional- is the physician payment

Coverage

As established in legislation, Medicare provides conditions of coverage for both screening and diagnostic mammography services. Coverage guidelines address the types of services covered; requirements for providers of service; patient’s eligibility; and frequency limitations. To review information on Medicare’s coverage conditions for mammography services, refer to Medicare’s National Coverage Determination, Mammograms, in the Internet Manual for Medicare National Coverage Determinations at http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf

(scroll to section 220.4), as well as information located in the Internet Manual for MedicareBenefit Policy at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf (scroll to section 280.3).