Janet Posted Tue 18th of September, 2018 10:00:12 AM
Has anyone had a problem with Medicare or other carriers denying the 77065 Scenario:
Patient has mammogram. The radiologist sees an area of concern and wants the patient to come back in for additional views, which would be billed as 77065 with the appropriate LT/RT modifier. The area of concern is still there so we do U/S, followed by a biopsy, with clip placement. Then we have to perform another mammogram to ensure the correct placement of the clip. This is billed as 77065,XU, RT or LT modifier. The radiologist has to read this mammogram and a report is generated
SuperCoder Answered Wed 19th of September, 2018 06:54:09 AM
The problem, however, seems to lie in the way the Centers for Medicare and Medicaid Services (CMS) has been handling payments for 77065. CPT® introduced 77065 mammography codes effective Jan. 1, 2017. However, the Medicare Physician Fee Schedule (PFS) assigned a status of "I" to these codes, "indicating that these codes are not payable under the PFS until Jan. 1, 2018".
In other words, Medicare was not paying for any 77065 services for the entire 2017 calendar year. Instead, CMS instructed providers to report code G0206 (Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral) rather than 77065 on claims with dates of service Jan. 1, 2017 through Dec. 31, 2017.
On February 2, 2018, CMS released Transmittal 3961, which contained "instructions to modify system edits to pay claims containing code 77065, 77066, or 77067".
So, CMS will be paying for 77065 moving forward, but you should check with your Medicare Administrative Contractor (MAC) to see if CMS will process claims with dates of service prior to Jan. 1, 2018, with that code or whether you need to re-submit with code G0206 in lieu of 77065.
Please confirm the date on your claim.
Janet Posted Wed 19th of September, 2018 11:42:39 AM
These dates of service that are being denied are 2018. They are not paying for the second 77065 with the XU modifier for the clip placement mammogram. They are saying it is the MUE (they will not pay for 2 in one day)? appeal did not get payment ? any ideas?Thanks, Janet
SuperCoder Answered Thu 20th of September, 2018 02:42:40 AM
As per CPT guidelines, CPT 77065 can be billed only 1 time per day as its MUE value is 1. You will not get paid for second one.