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
CPT®1 code/description
Modifiers
Documentation requirements2
Payment methodologies for ultrasound services
Site of service
Coverage information
States with coverage information3
Documents / Resources

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

Documents / Resources

| GE HealthCare 2024 Reimbursement For Automated Breast Ultrasound Screening [pdf] User Guide
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