CMS Pub. 100-04, ch. 18, § 20.4

A/B MACs use the weekly-updated MQSA file to verify that the billing facility is certified by the

FDA to perform mammography services, and has the appropriate certification to perform the type

of mammogram billed (film and/or digital). (See §20.1.) A/B MACs (A) use the provider number

submitted on the claim to identify the facility and use the MQSA data file to verify the facility’s

certification(s). A/B MAC (A) complete the following activities in processing mammography

claims:

• If the provider number on the claim does not correspond with a certified mammography

facility on the MQSA file, then A/B MACs (A) deny the claim.

• When a film mammography HCPCS code is on a claim, the claim is checked for a “1”

film indicator.

• If a film mammography HCPCS code comes in on a claim and the facility is certified for

film mammography, the claim is paid if all other relevant Medicare criteria are met.

• If a film mammography HCPCS code is on a claim and the facility is certified for digital

mammography only, the claim is denied.

• When a digital mammography HCPCS code is on a claim, the claim is checked for “2”

digital indicator.

• If a digital mammography HCPCS code is on a claim and the facility is certified for

digital mammography, the claim is paid if all other relevant Medicare criteria are met.

• If a digital mammography HCPCS code is on a claim and the facility is certified for film

mammography only, the claim is denied.

NOTE: The Common Working File (CWF) no longer receives the mammography file for editing

purposes.

Except as provided in the following sections for RHCs and FQHCs, the following procedures apply

to billing for screening mammographies:

The technical component portion of the screening mammography is billed on Form CMS-1450

under bill type 12X, 13X, 14X**, 22X, 23X or 85X using revenue code 0403 and HCPCS code

77067* (G0202*).

The technical component portion of the diagnostic mammography is billed on Form CMS-1450

under bill type 12X, 13X, 14X**, 22X, 23X or 85X using revenue code 0401 and HCPCS code

77065* (G0206*),* 77066*(G0204).

Separate bills are required for claims for screening mammographies with dates of service prior to

January 1, 2002. Providers include on the bill only charges for the screening mammography.

Separate bills are not required for claims for screening mammographies with dates of service on or

after January 1, 2002.

See separate instructions below for rural health clinics (RHCs) and federally qualified health

centers (FQHCs).

* For claims with dates of service January 1, 2017 through December 31, 2017, providers report

CPT codes G0202, G0204, and G0206. For claims with dates of service January 1, 2018 and later,

providers report CPT codes 77067, 77066, and 77065 respectively.

** For claims with dates of service April 1, 2005 and later, hospitals bill for all mammography

services under the 13X type of bill or for dates of service April 1, 2007 and later, 12X or 13X as

appropriate. The 14X type of bill is no longer applicable. Appropriate bill types for providers other

than hospitals are 22X, 23X, and 85X.

In cases where screening mammography services are self-referred and as a result an attending

physician NPI is not available, the provider shall duplicate their facility NPI in the attending

physician identifier field on the claim.

20.4.1 - Rural Health Clinics and Federally Qualified Health Centers (Rev. 4225,

Issues: 02-01-19, Effective: 07-01-19, Implementation: 07-01-19)

A. Provider-Based RHC & FQHC - Technical Component

The technical component of a screening or diagnostic mammography is outside the scope of the

RHC/FQHC benefit. In a provider-based RHC or FQHC, the technical component is billed by the

base provider to the A/B MAC (A) under bill type 12X, 13X, 22X, 23X or 85X as appropriate

using the base provider’s outpatient provider number (not the RHC/FQHC provider number). The

revenue code for a screening mammography is 0403, and the HCPCS code is 77067*,

(G0202)*). The revenue code for a diagnostic mammography is 0401, and the HCPCS codes are

77065* (G0206*), 77066* (G0204*). Payment is based on the payment method for the base

provider.

**G0236 is a deleted code after December 31, 2003. Use 76082* for claims with dates of service

January 1, 2004 through December 31, 2006, and code 77051 for claims with dates of service

January 1, 2007 and later.

* For claims with dates of service January 1, 2017 through December 31, 2017, report CPT codes

G0206, G0204, and G0202. For claims with dates of service January 1, 2018 and later, report CPT

codes 77065, 77066, and 77067respectively.

B. Independent RHCs and Freestanding FQHCs - Technical Component

The technical component of a screening or diagnostic mammography is outside the scope of the

RHC/FQHC benefit. The practitioner that renders the technical service bills their A/B MACs (B)

using Form CMS-1500. Payment is based on the MPFS national non- facility rate.

C. Provider-Based RHC & FQHC, Independent RHCs and Freestanding FQHCs -

Professional Component

The professional component of a screening or diagnostic mammography is within the scope of the

RHC/FQHC benefit and is billed under the RHC AIR or the FQHC PPS payment methodology

with revenue code 052X. A/B MACs (A) should assure payment is not made for revenue code

0403 (screening mammography) or 0401 (diagnostic mammography). No payment is made on the

line item reporting revenue code 0403.

For claims with dates of service on or after April 1, 2005, RHCs and FQHCs bill the A/B MAC (A)

under bill type 71X or 77X for the professional component of a diagnostic mammography. No

payment is made for the professional component of a diagnostic mammography unless there is a

qualifying visit on the same day. The services should be billed with the appropriate revenue

code. HCPCS coding is required for the diagnostic mammography.