CMS Pub. 100-04, ch. 18, § 20

A. Screening Mammography

Beginning January 1, 1991, Medicare provides Part B coverage of screening mammographies for

women. Screening mammographies are radiologic procedures for early detection of breast cancer

and include a physician’s interpretation of the results. A doctor’s prescription or referral is not

necessary for the procedure to be covered. Whether payment can be made is determined by a

woman’s age and statutory frequency parameter. See Pub. 100-02, Medicare Benefit Policy

Manual, chapter 15, section 280.3 for additional coverage information for a screening

mammography.

Section 4101 of the Balanced Budget Act (BBA) of 1997 provides for annual screening

mammographies for women over age 39 and waives the Part B deductible. Coverage applies as

follows:

Age Groups Screening Period

Under age 35 No payment allowed for screening mammography.

35-39 Baseline (pay for only one screening mammography performed on a

woman between her 35th and 40th birthday)

Over age 39 Annual (11 full months have elapsed following the month of last

screening

NOTE: Count months between screening mammographies beginning the month after the date of

the examination. For example, if Mrs. Smith received a screening mammography examination in

January 2005, begin counting the next month (February 2005) until 11 months have elapsed.

Payment can be made for another screening mammography in January 2006.

B. Diagnostic Mammography

A diagnostic mammography is a radiological mammogram and is a covered diagnostic test under

the following conditions:

• A patient has distinct signs and symptoms for which a mammogram is indicated;

• A patient has a history of breast cancer; or

• A patient is asymptomatic, but based on the patient’s history and other factors the physician

considers significant, the physician’s judgment is that a mammogram is appropriate.

• Beginning January 1, 2005, Medicare Prescription Drug, Improvement, and Modernization

Act (MMA) of 2003, §644, Public Law 108-173 has changed the way Medicare pays for

diagnostic mammography. Medicare will pay based on the MPFS in lieu of OPPS or the lower

of the actual change.