Micheal N. Linver, MD

Over the past decade, breast imaging has achieved new levels of excellence, sending the death rate from breast cancer plummeting by almost 25% in the United States. 1 At the same time, the financial fiasco surrounding mammography has forced many breast imaging centers to the brink of monetary ruin. 2 Breast imagers cannot help but feel a sense of bitter irony and even betrayal that fiscal failure is their reward for their hard work and success in changing the natural history of this disease. Although many factors are responsible for the present situation, none has contributed more directly than the changes in the reimbursement system in this country over the last 2 decades. Profit and loss can be determined by a better understanding of the various systems of reimbursement now in play. Having a clear understanding of the appropriate coding and specific billing requirements of each third-party payor minimizes improper billing and subsequent reimbursement denials.


The ICD-9-CM code (International Classification of Disease-Ninth Revision- Clinical Modification) defines the medical indication for a service, and is evaluated by payors when establishing whether a service is appropriate for the medical condition under evaluation. This classification was begun and is overseen by the World Health Organization. 3 A covered diagnosis would still require appropriate submission of the procedure (CPT/HCPCS) code before payment would be forthcoming.

The Current Procedural Terminology (CPT) system was originally designed by the American Medical Association (AMA) to identify procedures performed by physicians (CPT codes and descriptions only are copyrighted by the AMA, all rights reserved). 4 To provide the needed specificity to differentiate one procedure from another, three additional modifying levels of CPT codes, known as the CPT/HCPCS codes, or CPT/Healthcare Common Procedure Coding System codes, were added by the Health Care Financing Administration, now known as the Centers for Medicare & Medicaid Services (CMS), the government body responsible for overseeing Medicare payment. 5


Medicare reimbursement underwent a major overhaul in the early 1990s, when Congress directed CMS to study physician payment reform. The resulting system, initiated by Medicare in 1992, is known as the Resource-Based Relative Value Scale (RBRVS). 6

RBRVS was created by the marriage of the existing CPT codes with a weighted system assigning a relative value to each physician procedure under what was to be known as the Medicare Fee Schedule (MFS). The MFS is considered to be resource-based, because the fee for a physician’s service is based on the resources needed to provide that service: physician work, practice expenses, and professional liability insurance costs. All three components for a particular service are then assigned a numerical value called a relative value unit (RVU). These values are then further adjusted regionally for local differences in resource costs. 7

To determine dollar reimbursement, one multiplies the respective geographic adjustments by the three RVU values assigned the service, adds them, and then multiplies the sum times the conversion factor. For 2002, the Medicare Fee Schedule conversion factor for radiology is $36.20, a decrease of 4.5% compared to 2001.

In April 2000, CMS published the final rules for a hospital outpatient prospective payment system (HOPPS) for hospital outpatient services. 8 HOPPS is intended to standardize Medicare reimbursement for procedures (technical component only) performed in outpatient facilities within a hospital, and reduce patient out-of-pocket expenses as well. By prohibiting the unbundling of nonphysician outpatient services, HCFA created instead 451 “bundled” Ambulatory Payment Classifications (APCs). HCFA assigned a payment weight based on the factors for each APC. Payment is then determined by using a conversion factor and geographic adjustment factors. In general, the APC payment scale is similar to what previously existed. However, two glaring exceptions are the unilateral and bilateral diagnostic mammogram (CPT codes 76090 and 76091), for which proposed payment for 2002 is $30.48, less than two thirds the technical fee for a screening mammogram.

APC codes apply only to the technical components of radiology services for Medicare patients in a hospital setting. Professional fees are determined by the usual MFS based on RBRVS. 9

Medicare payment rates are not fixed in stone: CMS seeks advice from the RVS Update Committee (RUC) of representatives from the AMA and 22 specialty organizations, including the American College of Radiology, to update the physician work component of the RVU scale each year, and uses this information to conduct a comprehensive review of all relative values every 5 years. HCFA accepted 90% of RUC recommendations in 1993 and 1998. It is through the RUC that the opportunity to increase reimbursement for breast imaging procedures in the near future is greatest.

TABLE 1. Acceptable ICD-9 codes for diagnostic mammogram, from a large Medicare carrier in the Northeast.

The one Medicare fee that is critical to the success of every breast imaging facility is the reimbursement for screening mammography, originally set by Congressional mandate, as proscribed in the Omnibus Budget Reconciliation Act of 1990. 10 Unfortunately for all struggling breast imagers, the initial reimbursement rate was set artificially low at $55, and remained artificially low over the next decade. Congress increased the pool of eligible women by extending yearly coverage to all Medicare-eligible women 40 and older via the Balanced Budget Act of 1997, 11 but did nothing to significantly improve reimbursement.

A statutory change did occur in December 2000, with the passage of HR4577, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA), which returned screening mammography to the purview of the MFS. The global rate for screening mammography for 2002 under MFS is $81.81, a substantial increase, but less than had been hoped for. Efforts to pass legislation further increasing screening mammography reimbursement are still under way. 12


TABLE 2. Acceptable ICD-9 codes for diagnostic mammogram from a large Medicare carrier in the Southwest.

The ICD-9-CM code for a screening mammogram, V76.12 (special screening examination for malignant neoplasm, breast), is universally accepted under federal mandate by all regional Medicare carriers. However, reimbursement codes for diagnostic mammography vary tremendously from one Medicare carrier to the next. While most payors adhere to the concept that diagnostic mammography is generally indicated when there are signs or symptoms suggestive of malignancy, their individual interpretation of acceptable diagnosis codes is surprisingly diverse. Table 1, on page 32, represents the ICD-9 codes for diagnostic mammography accepted for reimbursement by a large Medicare carrier in the Northeast. 13 Table 2 represents those codes from a large Medicare carrier in the Southwest. 14 Note the relatively few codes that are accepted and reimbursed by both carriers, and the large number reimbursed by only one of the two. It is therefore important to communicate with one’s own Medicare carrier as to the acceptability of these or other ICD-9-CM codes for diagnostic mammography.

TABLE 3. Selected examples of procedural CPT codes and current 2002 Medicare reimbursement (national average). APC rates have been delayed to approximately 4/1/2002.

Table 3 (page 36) lists examples of breast imaging-related procedural CPT codes and the corresponding reimbursement by Medicare for 2002. Included are the new CPT codes for computer-assisted detection (CAD). 15-18

In assessing the Medicare payment rates in Table 3, one must keep in mind that these are national averages, which do not reflect geographic adjustments made by individual regional carriers. Reimbursement by local Medicare carriers may vary by as much as 30% . 19


Under Medicare, a screening mammogram is defined as a “preventive measure when a person has no history or personal history of breast cancer.” It is “for routine screening of asymptomatic women, with or without a family history, and with or without a physician’s recommendation.” Thus, Medicare does not require a written requisition for a Medicare-eligible woman to receive a screening mammogram. If a woman requires a diagnostic mammogram because of clinical signs or symptoms of possible breast cancer, then Medicare does require a physician request. However, if a diagnostic mammogram is required for further evaluation of a screening-detected abnormality, then no physician request is required.

For 2002, Medicare now will reimburse for both a screening mammogram and a diagnostic mammogram on the same patient, even if both are performed on the same day, provided that the diagnostic mammogram was precipitated by an abnormal screening mammogram. Prior to 2002, Medicare would reimburse only for the diagnostic mammogram under these circumstances. Medicare does require the modifier “GG” to be attached to the diagnostic mammogram CPT code(s) for proper reimbursement in this situation.

Medicare will reimburse for one baseline screening mammogram between ages 35 and 40, and for yearly screening mammograms beginning at age 40 in Medicare-eligible women. Under the Lapsed Time Rule, screening in Medicare-eligible patients will not be covered unless at least 11 months have elapsed between screenings. Another Medicare rule relates to the “Advance Beneficiary Notice.” Here, the facility must notify the patient if the facility believes that Medicare may not pay for the mammogram, and must identify to the patient the specific reason why Medicare may not pay (eg, not enough elapsed time between screenings, patient does not meet Medicare age requirements). Further, the facility must have the patient acknowledge this notice in writing. Failure to do so means any denied charges cannot be passed on to the patient and, if the patient is erroneously billed, may constitute fraud, and subject the facility to heavy penalties. Medicare also requires the mammography center to be certified by the Food and Drug Administration.


Virtually all payors presently reimburse using the same CPT coding for procedures utilized by CMS for Medicare reimbursement. However, the amount of reimbursement and the conditions under which reimbursement is distributed vary considerably by payor group. Each private company has its own interpretation of the elapsed time rule, and holds each patient responsible for establishing her own eligibility for a mammogram. However, like the Medicare carriers, the private insurers will inevitably deny and delay payment for claims if they feel their particular rules for reimbursement have not been strictly followed.

Health maintenance organizations (HMOs) usually reimburse at rates arrived at through negotiation with individual facilities. These rates are usually calculated as a percentage of Medicare rates, and vary from one extreme to the other, depending on local competition. In general, HMO rules for reimbursement are more convoluted than those for private insurers, with their apparent intent again being to delay and deny payment for even the most legitimate claim for reimbursement.

Both HMOs and private payors often require preauthorization for certain breast imaging procedures, especially interventional procedures. If preauthorization is not requested and granted, most payors will not reimburse, regardless of other circumstances. Under Medicare rules, CMS does not require preauthorization for interventional breast imaging procedures, but Medicare carriers may choose to deny claims for payment later if they deem the procedures inappropriate for any reason.

The last significant, but rapidly vanishing, payor group is the cash-paying customer. Some states require that even self-paying patients must present a signed referral from the clinician before a facility performs the examination. Aside from this minor exception, the facility dictates the rules for payment.


Given the current level of reimbursement for most mammographic procedures, each mammography facility must adopt an aggressive and vigilant attitude to avoid financial failure. The strategy for success should be centered around implementation of the following measures:

1. Know and apply the above rules for reimbursement. By doing so, one can prevent the denial before the payors can deny, thereby beating them at their own game. A simple yet effective first step is to identify and correct the common causes of delay and denial: incorrect procedure ordered by the clinician, failure to obtain preauthorization from the payor prior to the desired procedure, application of incorrect ICD-9-CM and/or CPT code(s) to the procedure, improper documentation for the procedure provided by the radiologist in his or her dictated report, and provision of inadequate written documentation and/or incorrect billing information. 20

2. Appropriately combine the identification of the patient, the indication for the examination, and all applicable procedural codes with the report of the procedure itself. When doing so, verify that all the relevant information is accurately reflected in the dictated report. The report should have clear findings and conclusions, and should include correct identification of the mammogram as either screening or diagnostic, all views performed, and the clinical history, since payment is based on the correct ICD-9-CM code in addition to all applicable CPT codes. For interventional breast procedures, it is important to include all applicable CPT codes, as these procedures always include more than one code (see Table 3, page 36). Note that the 19102 and 19103 codes have a global period of zero days, thus allowing any biopsy-related pre- or post-procedure examination to be billed separately, as well as any consultation with the patient prior to and/or after the procedure (for E and M codes, see Table 3). Although controversial, E and M codes can be successfully billed by breast imagers, providing that proper and complete documentation is performed. Since many of the E and M codes appear to have been successfully unbundled from the interventional procedures, as shown above, CPT codes 99241 and 99211 should now be able to be billed with success. One must meet the E and M Documentation Guidelines to do so. Additional documentation criteria for consultations (99241) include a physician’s request for an opinion or advice, and a separate written report to the referring physician. The 1995 and 1997 Guidelines, as well as the proposed 2000 Guidelines released by CMS, can be obtained from the CMS Web site at www.hcfa.gov/medicare.mcarpti.htm .

3. Pay close attention to one’s coding and billing habits. If the radiologist is doing the coding and utilizing a short list of CPT codes (a cheat sheet), it is important to assure that it is accurate and current, including all the new codes for 2002. Otherwise, coding should be left in the hands of dedicated and well-trained staff personnel. One should follow the local Medicare Review Policy (LMRP) portion of Medicare Part B bulletins for any local policy change.

Certain coding and billing practices should be avoided. In particular, do not upcode inappropriately, and try not to rebill a patient for a procedure. If done too frequently, these actions create a suspicious situation that payors will target, setting up a potential adverse profile for one’s entire practice. 21

4. Solicit and cultivate the cooperation of the clinicians. One may have to educate clinicians and their staffs to make them aware of the following: first, they should send or fax a signed referral prior to performance of the examination. Second, clinicians must provide the appropriate clinical diagnosis for each examination. For example, they cannot list fibrocystic disease as the reason for a diagnostic mammogram, if this diagnosis is not biopsy-proven. Third, the clinician must fill out the requisition as correctly and completely as possible. This can best be accomplished with the help of a well-designed, user-friendly order form provided by the facility. Such a form should include: a checklist of procedures to be performed (eg, screening mammogram, diagnostic mammogram, breast ultrasonogram, ultrasound-guided core biopsy, ductogram), a checklist of the patient’s symptoms, if any (eg, pain, lump, thickening), and a diagram of the breasts for the purpose of marking the location of pertinent physical findings. It is also useful for the facility to indicate all office phone numbers, including a fax number, on the order form. By meeting regularly with all major clinician referrers and/or their respective staffs and apprising them of the importance of complying with the above conditions, one can avoid many reimbursement problems. 20

5. Train all facility personnel to be knowledgeable regarding these same billing issues, and to be fastidious in collecting all patient information relevant to billing. If possible, designate one or two billing staff as specialists in billing breast imaging procedures.

6. Perform periodic internal data-quality audits: compile and subdivide the causes for denials and delays of claims. Seek out and retrain those responsible, be they physicians or other staff members, to minimize recurrences. Although time-consuming, this approach offers obvious and immediate benefits. 21

7. Challenge payor denials, if they appear inappropriate or contradictory. If necessary, arrange to meet with key payor personnel to review one’s legitimate claims. A little well-placed explanation of what one actually does for the customers (patients) may go a long way toward increasing reimbursement.

8. When negotiating with HMOs, use one’s own mammography outcome data to demonstrate that finding earlier, smaller cancers with mammography translates into dollar savings for the HMO. Further, if one’s call-back rate is low and positive biopsy rate appropriately high, one can argue even more effectively for the savings to the HMO. By demonstrating such outcomes, one may be able to negotiate a carve-out for proportionally higher reimbursement from the HMO for breast imaging procedures as compared to other imaging modalities.

9. Do not forget about making services attractive for the cash-paying customers by offering a discount. If not participating with Medicare, one can even negotiate individual contracts with patients (usually discounting 20% for cash payment). In doing so, one must also treat all patients the same, so the discount rate chosen must be consistent. Additionally, one cannot waive co-pays, and must bill at least once. Professional courtesy discounts should not be offered.

10. Get involved politically by mobilizing patient’s and women’s advocacy groups to support legislation increasing mammography reimbursement. Such groups represent the single most powerful weapon in the battle for better reimbursement.


As mammographers continue to face the ongoing problems of rising costs and falling reimbursement, their understanding of coding and billing as related to the current reimbursement system is critical to their very survival. By effectively translating such information into a careful coding and billing strategy for success, they can more realistically anticipate the day when their breast imaging facilities evolve from life-saving loss leaders to true financial profit centers.

Michael N. Linver, MD, is director of mammography, X-ray Associates of New Mexico, PC, and clinical associate professor, Department of Radiology, University of New Mexico School of Medicine, Albuquerque.


  1. Peto R, Boreham J, Clarke M, et al. UK and USA breast cancer deaths down 25% in year 2000 at 20-69 years. Lancet. 2000;355:1822-1830.
  2. Brice J. Mammography in jeopardy. Diagnostic Imaging. 2001;23(2):50-55.
  3. International Classification of Diseases, Ninth Revision, Clinical Modification, Sixth Edition. Salt Lake City: Ingenix Publishing Group; 2000.
  4. Current Procedural Terminology: CPT 2001 Professional Edition. Chicago: American Medical Association; 2000.
  5. HCPCS National Level II Codes 2001. Salt Lake City: Ingenix Publishing Group; 2000.
  6. Mitchell JB. Physician DRGs. N Engl J Med. 1985;313:670-675.
  7. Department of Health and Human Services- Health Care Financing Administration: Medicare Program: Revisions to payment policies and adjustments to the relative value units under the physician fee schedule for calendar year 1999- final rule and notice. 63 Federal Register. 211.
  8. Department of Health and Human Services- Health Care Financing Administration Prospective payment system for hospital outpatient services. 65 Federal Register. 68:18433-18482, 2000.
  9. Farria DM. The Hospital Outpatient Prospective Payment System: an overview. Seminars in Breast Disease. 2001;4(1):21-26.
  10. Department of Health and Human Services: Interim final rules on conditions for Medicare coverage of screening mammograms. Federal Register. 1990:53511-53525.
  11. Balanced Budget Act of 1997 (Medicare revisions), Section 4104. Public Law 105-33.
  12. Assure Access to Mammography Act of 2001 (Enhanced reimbursement for screening mammography under the Medicare program), SB-548.
  13. Radiology Coding Alert, sample issue, 1-3, 1999.
  14. Medicare Providers’ News Part B Oklahoma/New Mexico, November 1997.
  15. Department of Health and Human Services: 2002 Physician Fee Schedule, Federal Register. November 1, 2001.
  16. Hayek D (Economics and Health Policy Department, American College of Radiology), personal communication, 2002.
  17. Kolb GR (Breast Health Management, Inc., [email protected]), personal communication, 2002.
  18. Granucci S (Healthcare Reimbursement Specialist, [email protected]), personal communication, 2002.
  19. Brice J. Small change for big medicine. Diagnostic Imaging. 2000;22(9):42-49.
  20. Ikeda DM, Linver MN. ICD-9-CM codes, CPT codes, billing and collection. SBI News. October 2000:1, 7-9.
  21. Yoder L, Anderson R. Assess your practice’s coding intelligence. Axis Imaging News. July-August 1999:74-80.