CMS Pub. 100-04, ch. 18, § 20.3.1

January 1, 2002

(Rev. 3844, Issued: 08-18-17, Effective: 01-01-18, Implementation: 01-02-18)

The payment limitation methodology does not apply to claims with dates of service on or after

January 1, 2002.

A/B MAC (A) Claims

For claims with dates of service on or after January 1, 2002, §104 of the Benefits Improvement and

Protection Act (BIPA) 2000, provides for payment of screening mammography under the Medicare

physician fee schedule (MPFS) when furnished in hospitals, skilled nursing facilities (SNFs), and

CAHs not electing the optional method of payment for outpatient services. However, payment

under the physician fee schedule is not applicable to hospitals subject to the Outpatient Prospective

Payment System (OPPS) until April 1, 2002.

The payment for code 77067* is equal to the lower of:

• The actual charge or

• Locality specific technical component payment amount under the MPFS.

Part B deductible and coinsurance does not apply. This is a final payment.

A/B MACs (A) use the benefit-pricing file provided by CMS to pay mammography codes.

Payment for the add-on code 76085 is made under the Medicare Physician Fee Schedule.

Deductible does not apply, however, coinsurance is applicable.

*For claims with dates of service prior to January 1, 2007, providers report CPT code 76092. For

claims with dates of service January 1, 2007 and later, providers report CPT code 77057.

A/B MACs (B) Claims

Physicians and suppliers are paid by the A/B MACs (B) for all mammography tests (including

screening mammography) under the MPFS. Separate prices for the technical component, the

professional component and the global service are included on the MPFS.

The Medicare allowed charge is the lower of:

• The actual charge, or

• The MPFS amount for the service billed.

The Medicare payment for the service is 80 percent of the allowed charge. Coinsurance is 20

percent of the lower of the actual charge or the MPFS amount. Part B deductible is waived and

does not apply to screening mammography.

As with other MPFS services, the nonparticipating provider reduction and the limiting charge

provisions apply to all mammography tests (including screening mammography).