CMS Pub. 100-04, ch. 18, § 20.3.1.2.1

Payment for Screening Mammography in the Critical Access Hospital Outpatient Setting

Method 1 (Standard)

TOB Rev

Code

HCPCS Payment

Services on or after January 1 2002

Technical Component

Deductible does not apply.

Coinsurance based on charge.

85X 403 77067*

(G0202)*

A/B MAC (A)

payment is 80%

of the lower of

the charge or the

fee schedule

amount.

Professional Component

Deductible does not apply.

Coinsurance based on lower of MPFS

or charge.

77067*

(G0202)*

A/B MACs (B)

payment is 80%

of the lower of

the charge or

MPFS amount

for the technical

component. The

new A3 states

payment for

76092 is lower of

charge or locality

specific

TECHNICAL

component

amount under

MPFS.

Method 2 (Optional Method) - Option available with cost reporting periods starting on or

after October 1, 2001 and dates of service on or after July 1, 2001.

TOB Rev

Code

HCPCS Payment

Services on or after January 1 2002

Technical Component

Deductible does not apply.

Coinsurance based on charge.

85X 403 77067*

(G0202)*

A/B MAC (A)

payment is 80%

of the lower of

the charge or the

fee schedule

amount.

Professional Component

Deductible does not apply.

Coinsurance based on lower of

MPFS or charge.

85X 96X,

97X,

or 98X

77067*

(G0202*)

A/B MAC (A)

pays 115% of

80% (that is 92%)

of the lower of

the charge or the

MPFS amount.