GE HealthCare 2024 Reimbursement For Automated Breast Ultrasound Screening User Guide
- July 25, 2024
- GE Healthcare
Table of Contents
2024 Reimbursement For Automated Breast Ultrasound Screening
Reimbursement guide for automatedbreast ultrasound screening
2024
For additional resources, please visit the ABUS Club.
https://www.abusclub.net/us/home
Disclaimer
The information provided with this notice is general reimbursement information
only; it is not legal advice, nor is it advice about how to code, complete or
submit any particular claim for payment. It is always the provider’s
responsibility to determine and submit
appropriate codes, charges, modifiers and bills for the services that were
rendered. This information is provided as of January 1, 2024, and all coding
and reimbursement information is subject to change without notice. Payers or
their local branches may have distinct coding and reimbursement requirements
and policies. Before filing any claims, providers should verify current
requirements and policies with the local payer. Third party reimbursement
amounts and coverage policies for specific procedures will vary including by
payer, time period and locality, as well as by type of provider entity. This
document is not intended to interfere with a healthcare professional’s
independent clinical decision making. Other important considerations should be
taken into account when making decisions, including clinical value. The
healthcare provider has the responsibility, when billing to government and
other payers (including patients), to submit claims or invoices for payment
only for procedures which are appropriate and medically necessary. You should
consult with your reimbursement manager or healthcare consultant, as well as
experienced legal counsel.
The Invenia™ ABUS is indicated as an adjunct to mammography for breast cancer
screening in asymptomatic women for whom screening mammography findings are
normal or benign (BI-RADS® Assessment Category 1 or 2), with dense breast
parenchyma (BI-RADS Composition/Density C or D), and have not had previous
clinical breast intervention. The device is intended to increase breast cancer
detection in the described patient population. The Invenia ABUS may also be
used for diagnostic ultrasound imaging of the breast in symptomatic women.
Current Procedural Terminology (CPT) ®1 coding and Medicare reimbursement
The following table provides CPT®1 coding routinely used for ABUS. Please
consult your reimbursement specialist for more information.
CPT®1 code/description
CPT 76641
Ultrasound, breast, unilateral, real time with image documentation, including
axilla when performed; complete
CPT 76642
Ultrasound, breast, unilateral, real time with image documentation, including
axilla when performed; limited
- Four-quadrant and retroareolar region imaging required for “complete” examination. Axilla imaging may or may not be performed.
Please refer to the CMS guidance on the appropriate fee schedule:
https://www.cms.gov/medicare/medicare-fee-for-service-payment/pfslookup
Modifiers
Modifiers explain that a procedure or service was changed without changing the definition of the CPT code set. Here are some common modifiers related to the use of ultrasound for breast procedures.
26 – Professional Component
A physician who performs the interpretation of an ultrasound exam in the
hospital outpatient setting may submit a charge for the professional component
of the ultrasound service using a modifier (-26) appended to the ultrasound
code.
50 – Bilateral Procedure
This modifier would be used to bill bilateral procedures that are performed at
the same operative session, unless otherwise identified in the listings. To
appropriately adjust payment when bilateral procedures are furnished under the
PFS, payments are adjusted to 150 percent of the unilateral payment when a
service has a bilateral payment indicator assigned.
TC – Technical Component
This modifier would be used to bill for services by the owner of the equipment
only to report the technical component of the service. This modifier is most
commonly used if the service is performed in an Independent Diagnostic Testing
Facility (IDTF).
ICD-10-CM and ICD-10-PCS
ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) codes were implemented
October 1, 2015. It is the physician’s ultimate responsibility to select the
codes that appropriately represent the service performed, and to report the
ICD-10-CM code based on his or her findings or the pre-service signs, symptoms
or conditions that reflect the reason for doing the mammography. Examples are
provided of ICD-10-CM diagnosis and ICD-10-PCS procedure codes that relate to
breast ultrasound procedures for breast cancer screening.
ICD-10-CM (diagnosis)
- R92.0 Mammographic microcalcification found on diagnostic imaging of breast
- R92.1 Mammographic calcification found on diagnostic imaging of breast
- R92.2 Inconclusive mammogram
- R92.3 Mammographic density found on imaging of the breast
- R92.8 Other abnormal and inconclusive findings on diagnostic imaging of breast
- Z12.39 Encounter for other screening for malignant neoplasm of breast
ICD-10-PCS (procedure)
- BH40ZZZ Ultrasonography of Right Breast
- BH41ZZZ Ultrasonography of Left Breast
- BH42ZZZ Ultrasonography of Bilateral Breasts
For more information on ICD-10-CM/PCS, please go to: https://www.cms.gov/medicare/Coding/ICD10/index.html
Documentation requirements2
Ultrasound performed using either a compact portable ultrasound or a console ultrasound system are reported using the same CPT codes as long as the studies that were performed meet all the following requirements:
- Medical necessity as determined by the payer
- Completeness
- Documented in the patient’s medical record
A separate written record of the diagnostic ultrasound or ultrasound- guided
procedure must be completed and maintained in the patient record. This should
include a description of the structures or organs examined the findings and
reason for the ultrasound procedure. Diagnostic ultrasound procedures require
the production and retention of image documentation. It is recommended that
permanent ultrasound images, either electronic or hardcopy, from all
ultrasound services be retained in the patient record or other appropriate
archive.
Note: The description of the code 76641 states that axilla imaging is not
required, but included in the code description if performed. Therefore, if
this is part of the examination, it should be documented in the patient files
that it was performed.
Payment methodologies for ultrasound services
Medicare may reimburse for ultrasound services when the services are within the scope of the provider’s license and are deemed medically necessary. The following describes the various payment methods by site of service.
Site of service
Physician office setting
In the office setting, a physician who owns the ultrasound equipment and
performs the service, or a sonographer who performs the service, may report
the global code without a –26 modifier.
Hospital outpatient
When the ultrasound is performed in the hospital outpatient setting,
physicians may not submit a global charge to Medicare because the global
charge includes both the professional and technical components of the service.
If the procedure is performed in the hospital outpatient setting, the hospital
may bill for the technical component of the ultrasound service as an
outpatient service.
The CPT code filed by the hospital will be assigned to a hospital outpatient
system Ambulatory Payment Classification (APC) payment system, and payment
will be based on the APC grouping. However, for Medicare, the hospital
outpatient facility and the physician must report the same CPT code. If the
physician is a hospital employee, the hospital may submit a charge for the
global service.
Hospital inpatient setting
Although this service would not typically be performed in the inpatient
hospital setting, if it is performed in this setting, charges for the
ultrasound services occurring in the hospital inpatient setting are likely to
be considered part of the charges submitted for the inpatient stay and payment
is likely to be made under the Medicare MS-DRG payment system. However, the
physician may still submit a bill for his/her professional services
regardless.
Note: Medicare may reimburse for ultrasound services when the services
are within the scope of the provider’s license and are deemed medically
necessary.
Coverage information
Procedures may be a covered benefit if such usage meets all requirements established by the particular payer. However, it is advisable that you verify coverage policies with your local Medicare Administrative Contractor. Also, it is essential that each claim be coded appropriately and supported with adequate documentation in the medical record. Coverage by private payers varies by payer and by plan with respect to which medical specialties may perform ultrasound services. Some private payer plans will reimburse for ultrasound procedures performed by any physician specialist while other plans will limit ultrasound procedures to specific types of medical specialties. In addition, plans may require providers to submit applications requesting these diagnostic ultrasound and ultrasound-guided services be added to the list of services performed in their practice. It is important that you contact the payer prior to submitting claims to determine their requirements.
States with coverage information3
ABUS or Whole Breast Ultrasound is covered under preventative care for some commercial payors; however, self-funded plans may require an out-of-pocket cost.
For information on dense breasts and state-level insurance coverage, visit www.DenseBreast-Info.org https://www.gehealthcare.com/products/ultrasound/breast-ultrasound/invenia- abus
- CPT codes and descriptions only are copyright © 2021 American Medical Association. All rights reserved. No fee schedules are included in CPT. The American Medical Association assumes no liability for data contained or not contained herein.
- Certain Medicare carriers require that the physician who performs and/or interprets some types of ultrasound examinations to prove that they have undergone training through recent residency training or post-graduate CME and experience. For further details, contact your Medicare contractor.
- Information through January 2024. https://densebreast-info.org/legislative-information/state-legislation-map/.
For further details, contact your Medicare contractor.
Products mentioned in the material may be subject to government regulations
and may not be available in all countries. Shipment and effective sale can
only occur after approval from the regulator. Please check with local GE
HealthCare representative for details.
© 2024 GE HealthCare. Invenia is a trademark of GE HealthCare. Windows is a
registered trademark of Microsoft Corporation. BI-RADS is a trademark of the
American College of Radiology. CPT is a trademark of the American Medical
Association. GE is a trademark of General Electric Company used under
trademark license.
March 2024
JB00702US
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