Tips and tactics for providers seeking reimbursement for adjuvant screening breast ultrasound.

Three states (Connecticut, Texas, and Virginia) now have laws requiring the notification of women if their screening mammograms revealed that they had radiographically dense breasts. The wording of the laws differs between the states, but they share the following aspects:

  • They notify the woman of her density;
  • They tell the woman that dense breast tissue can make it harder to find a cancer on the mammogram;
  • There may be other screening methods that could be beneficial or useful; and
  • The woman should discuss density and screening with her physician.

Of the current notification laws, only Connecticut also mandates payment for adjuvant screening ultrasound, and the tendency in the 13 states that are considering some form of density legislation is to mandate only notification. The omission is largely intentional, as with 40% to 50% of women who are eligible for screening mammography having dense breasts, they are afraid of the impact of the cost on their own Medicaid programs. Screening providers cannot, however, inform individual women that their mammogram is largely ineffective unless they undergo an adjuvant procedure, without creating demand for such procedures, and legislative silence is creating a 900-pound gorilla that must be faced by screening providers.

Since 2009, we have had a diagnosis code (ICD-9-cm 793.82) to describe inconclusive mammography due to density, and the language of CPT™ 76645 is now broad enough to describe screening ultrasound, so the nomenclature is in place for billing. Most would argue that the reimbursement is insufficient for the more resource-intensive screening procedure, but the challenge has been that many third-party payors will not reimburse for ICD-9 793.82.

Gerald R. Kolb, VP, Business Development, Matakina International, Ltd

To not provide access to adjuvant screening ultrasound because of the lack of universal reimbursement would be improper on several different medicolegal and ethical levels that are beyond the scope of this article. This combination of circumstances leaves mammography providers in a deep quandary in both notification and non-notification states, as we must assume that the woman’s right to knowledge about her breast density will become nationally recognized in time.

In the 3 years since the Connecticut law went into effect, several ideas have come to the front for making the system work in both notification states and those that have not yet adopted notification standards. There are still challenges, and all of the solutions have certainly not yet been developed, but we have collected a number of the more successful approaches to providing screening ultrasound:

  • Educate—The most important thing you can do is to inform referring physicians and patients of the effect of density on the sensitivity of the mammogram, and the ability of ultrasound to “see through” dense tissue to find small cancers.
  • Determine Density Objectively—Subjective density determination by the physician is very operator dependent. Use of an FDA-cleared technology (Volpara®, Quantra™) can automate determination and provide objectivity, which is important to validation of the referral for adjuvant screening.
  • Accommodate—You need to establish a reasonable schedule for providing screening ultrasound—whether handheld or automated—for patients in a timely manner. Scheduling delays will reduce compliance, and they also will cause the loss of mammography patients to other, more proactive facilities.
  • Charge—In states that do not mandate payment, you must implement a reasonable charge for screening ultrasound and offer the procedure on a patient pay basis. Expect that many payors will push back on payment, but be prepared by having patients sign an advanced beneficiary notice accepting the payment obligation.
  • Manage Workflow—Experience has shown that patient accrual for screening ultrasound is several times higher if women are offered the procedure at the same time as their mammogram. This is best accomplished by protocol, using objective density measurement from the screening mammogram. Providing the second service during the same visit eliminates the nonmedical cost of a second visit for the provider that is estimated at $25 to $75.
  • Start at Home—Providers should make certain that the third-party administrator of their benefits plans pays for screening ultrasound for employees. Being able to indicate that your employees are covered for screening ultrasound provides powerful ammunition in the argument to other payors for payment.
  • Be Proactive—All denials of payment provide the opportunity for arguing the need for coverage. Provide pro forma letters to patients whose insurance denies coverage for them to request that screening ultrasound become a covered procedure.
  • Celebrate—Within the restrictions of HIPAA, celebrate each mammographically occult cancer that is discovered by adjuvant screening. Inform referring physicians in your newsletter, announce the event on your Web site, and make sure your staff and members of the radiology group who are not involved in breast imaging understand that you have discovered a cancer earlier than it would have otherwise been found.

Each of the foregoing is important individually, and you will find that as you add them up, there is a multiplier effect. As anyone who is involved in breast imaging already knows, finding cancers when they are small and more treatable is a goal of every mammography provider, and adding a tool to the screening process allows us to achieve that goal for more of our patients.

Gerald R. Kolb has had a 20-year career in breast health and is currently the vice president of business development for Matakina International, Ltd.