Knowledge Base Article

Q:

Our facility has recently started performing digital mammography, but Medicare is denying all of the charges for HCPCS codes 77063 (screening digital tomosynthesis for mammography) and G0279 (diagnostic digital breast tomosynthesis, unilateral or bilateral). Do you know what could be causing these denials?

A:

There are a couple of reasons why you could be receiving these denials. You should be able to determine the reason from the Claim Adjustment Reason Code (CARC) on your remittance.

Lack of Primary Code

One possibility is that you are reporting these add-on codes without the primary code.

• CPT code 77063 must be reported with CPT 77067 (screening mammography).
• HCPCS code G0279 is to be listed separately in addition to CPT codes 77065 (diagnostic mammogram, unilateral) or 77066 (diagnostic mammogram, bilateral).

The manual wording from the Medicare Claims Processing Manual, chapter 18 , section 20.2.1 indicates CPT code 77063 will be returned to the provider for institutional claims if billed without 77067, but HCPCS code G0279 will be denied if not reported with the appropriate code.

 “Effective for claims with dates of service January 1, 2018 and later A/B MACs (A) and (B) must assure that claims containing code G0279 also contain HCPCS code 77065 or 77066. A/B MACs (A) or (B) deny claims containing code G0279 that do not also contain HCPCS code 77065 or 77066 with an explanation that payment for code G0279 cannot be made when billed alone.”

Lack of Appropriate FDA Certification Status

We have seen denials of the two codes (77063 and G0279) on claims with a CARC of 171- “Payment is denied when performed/billed by this type of provider in this type of facility.” We believe this is related to lack of appropriate FDA certification. See CMS Transmittal R1387CP or section 20.1 of the Medicare Claims Processing Manual, chapter 18.

All facilities providing screening and diagnostic mammography services (except VA facilities) must be certified by the Food and Drug Administration (FDA). The FDA maintains this data in the Mammography Quality Standard Act (MQSA) file and shares the file with CMS and their contractors weekly. The MQSA indicates whether a facility if certified to perform film or digital mammography.

CMS contractors rely on the FDA certification data contained in the MQSA file to know whether the mammography facility is certified to perform digital mammography. Contractors will deny a claim for a mammography service if the nature of the billed HCPCS code (i.e., film or digital) does not correspond to the FDA certification status listed on the MQSA file for the billing mammography facility.  This means if the FDA MQSA file does not indicate a facility is certified to perform digital mammography, the Medicare contractor will deny the HCPCS codes for these digital mammography services, i.e. HCPCS codes 77063 and G0279.