By Jenny Lower

Digital breast tomosynthesis (DBT), also known as 3D mammography, has attracted significant interest in recent years among researchers and physicians for its potential to improve detection of breast cancer, particularly in women with dense breasts. For the first time, the modality received new billing codes and reimbursement rates in the final rule for the 2015 Medicare Physician Fee Schedule (MPFS). While the decision marks a positive step in the trend toward broader adoption of this technology, the American College of Radiology (ACR) points to remaining gaps and it hopes to see the Centers for Medicare and Medicaid Services (CMS) address them in the future.

Geraldine McGinty, MD

Geraldine McGinty, MD

“We’re obviously happy to see CMS decide to cover the service, but we definitely have some concerns about the code structure they put in place,” said Geraldine McGinty, MD, chair of the ACR Economics Commission and a breast imager at Weill Cornell Medical College in Manhattan. The ACR led the code-change proposal with the Current Procedural Terminology (CPT) Editorial Panel and made recommendations to the Relative Value Scale (RVS) Update Committee (RUC) for valuation of the codes. The organization also commented extensively to CMS on implementation of the code structure, but the final rule diverged on a couple of important points.

While the ACR recommended adoption of three DBT codes—one for screening, one for diagnostic unilateral, and one for diagnostic bilateral—and the CPT panel created them, CMS recommended against using the diagnostic codes in 2015. Instead, CMS created a new G-code to be used as an add-on in combination with full-field digital mammography. The screening CPT code is also devised as an add-on, making it impossible to receive reimbursement for screening or diagnostic DBT as stand-alone services.

“The diagnostic tomosynthesis code is structured as an add-on code so that it always has to be done with a mammogram. We don’t believe that is always going to be the case,” McGinty said. “With diagnostic, you’re talking more about a problem-solving examination, so in some cases tomosynthesis on its own would be adequate.”

The ACR also expressed concern that both diagnostic and screening DBT were valued at the same rate—approximately $56, depending on the conversion factor and geographic area in play. According to McGinty, diagnostic DBT requires more time and effort for the radiologist compared to screening DBT, and she believes it should be valued at a higher rate.

Finally, a Correct Coding Initiative edit stipulates that providers can’t bill computer-aided detection (CAD), a technology used with digital mammography, on the same day as tomosynthesis. As an attempt to prevent medical billing redundancies, the effort is mistaken, McGinty said, since CAD and DBT are distinct techniques with no overlap. “That’s sort of giving with one hand and taking away with the other,” she said.

Any potential changes won’t be seen until the 2016 rule, which typically appears for comment in early July. Despite the current version’s shortcomings, the move now allows reimbursement for all radiologists practicing DBT regardless of setting, and may help stimulate wider interest. Though a perception of DBT as an “experimental” technology still persists among many private payors, the ACR is working to educate them about the benefits of tomosynthesis.

In McGinty’s own practice, both referring physicians and patients are already well aware of tomosynthesis as an option against breast cancer, she said. “We believe it’s a very promising technology. Having more tools to detect this disease early so it can be appropriately managed is always better.”


Jenny Lower is the associate editor for AXIS.

Get AXIS e-newsletters free. Subscribe here.