The Challenge of Protecting Mammography

The ACR Commission on Economics continues its efforts to maintain the economic viability of mammography services.mammogram

The coding and payment structure for mammography services changes on Jan. 1, 2017. Over the past three years, the Commission on Economics has worked to ensure the best outcomes for mammography services.

The immediate outcomes for 2017 are favorable, and we are prepared to deal with the remaining issues.

Coding and payment for mammography services has been relatively stable since the early 2000s, when the Benefits Improvement and Protection Act of 2000 (BIPA) passed. The act mandated coverage and payment for full-field digital mammography (FFDM) services under Medicare and prompted the creation of three new G codes to describe digital mammography. G codes are created unilaterally by CMS, usually due to a secondary mandate such as BIPA. The payment rate for the professional component, or PC, of digital mammography services (which includes the radiologist's reading of the study) became the same payment rate as the existing film screen (analog) codes. The technical component (or TC, which overs the practice expenses associated with conducting an exam) correspond to one and a half times the existing TC of the analog codes, based on payment mandates in BIPA.

CAD codes

Circumstances changed in late 2013. At that time, the RVS Updated Committee (RUC) and its Relativity Assessment Workgroup identified the FFDM G codes as "potentially misvalued," based on their "CMS/Other" time source. The ACR's arguments that the G codes were set by law (under BIPA) and exempt from action by the RUC proved unsuccessful. At that point, the ACR had to do something, either revalue the exis

The ACR elected to create new CPT codes to include all mammography services, whether FFDM or analog, and we bundled CAD (see sidebar). The outcome of the valuation of these new codes is favorable for 2017, including an increase in their PC valuation compared with the predecessor codes. This increase is the result of the work associated with the increase in radiologist-patient interactions inherent to mammography.ting codes or update the code structure. We decided to update the code structure. Two general trends in mammography services influenced our decision: digital mammography and computer assisted direction (CAD) had now become "typical." Services are considered by the RUC to be typical when they are performed more than 50 percent of the time.

 

CMS evaluated the TC payments in relation to the practice expense RVUs (PE RVUs), which would have occurred, based on the RUC recommendations and determined that "the technical component of these services ... could possible be reduced up to 50 percent relative to the PE RVUs currently used for payment for these services.... We are concerned that making drastic changes in coding and payment for these services could be disruptive in ways that could affect beneficiary access to the necessary services." Therefore, CMS is maintaining the existing TC payments but states that it "will consider the recommended inputs, including the pricing of the required equipment, as carefully as possible prior to proposing revised PE values through subsequent rulemaking."

As these changes to the base mammography codes were evolving, the ACR spearheaded the creation of three new CPT codes for digital breast tomosynthesis, which came into effect for 2016. However, CMS elected to implement on the screening tomosynthesis code (77063) and created a G code (G0279) to described diagnostic tomosynthesis. CMS cited the need to await the outcome of the FFDM coding changes before implementing the tomosynthesis codes. For 2017, CMS delayed action on the tomosynthesis code again.

Despite the favorable outcomes for mammography services in 2017, there is still much work to be done. CMS intends to further consider the TC payments based on the RUC recommendations for 2018. With talented clinical experts on our side, the Commission on Economics continues to protect payment and patient access to breast imaging and interventions. And maintaining payments for 2017 is a nice short-term win. Ensuring continued success in the future will require even more work. The Commission on Economics stands read to accept and overcome any new challenges.


dr silvaBy Ezequiel Silva III, MD, FACR, Chair

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