CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Mammography Screening Payment Policy 01.01.23

Payment policy governing reimbursement, coding, documentation, and medical necessity criteria for screening and diagnostic mammography for Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business. Includes screening frequency guidance for average- and high-risk women and coding guidance for specific mammography CPT/HCPCS codes.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMammography Screening Payment Policy 01.01.23

Policy CodePolicy N/A

Change TypeAnnual reviews and minor content/format updates

Effective DateSep 1, 2010

Next Review Date

Key ActionProviders must maintain medical records supporting services billed and medical necessity; Neighborhood may request records and follows CMS documentation standards.

SourceLink

POLICY UPDATE CHANGES

01/01/2023 Action = Annual Policy Review Date.

11/30/2021 Action = Policy Review Date.

10/21/2021 Action = Content and format updates.

09/01/2013 Action = Format change, minor edits.

09/01/2010 Action = Policy Effective Date

3Age-based screening categories

2Max annual screens for high-risk/recent cancer

2Screening frequency options for older women

Purpose: Mammography is used for early detection of breast cancer; screening is intended for asymptomatic individuals to find disease before symptoms occur. Scope: This payment policy governs reimbursement, coding, documentation, and medical necessity criteria for screening and diagnostic mammography for Medicaid excluding Extended Family Planning (EFP), INTEGRITY, and Commercial lines of business. Coverage applies to women at average risk (no personal history of breast cancer, no strong family history, no high-risk genetic mutation, and no chest radiation before age 30) with age-based frequency guidance: women 40–44 may start annual screening; women 45–54 annual; women 55+ biennial or annual while in good health and with a life expectancy of at least 10 years. Exceptions: up to 2 screening mammograms per year are allowed when recommended by a physician for women treated for breast cancer within the last 5 years or for women at high risk (BRCA mutation or multiple first-degree relatives), high-risk lesion on prior biopsy (lobular carcinoma in situ), or atypical ductal hyperplasia. Policy effective date: 09/01/2010; last review: 01/01/2023.

Key Header

Policy TitleMammography Screening Payment Policy

PayerNeighborhood Health Plan of Rhode Island

Policy NumberN/A

Effective Date2010-09-01

Last Review2023-01-01

Next Review

StatusCURRENT

ScopePayment policy governing reimbursement, coding, documentation, and medical necessity criteria for screening and diagnostic mammography for Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business. Includes screening frequency guidance for average- and high-risk women and coding guidance for specific mammography CPT/HCPCS codes.

Medical necessity and coverage criteria

Medical Necessity / Reimbursement Criteria for Screening Mammography

Covered when ALL of the following are met:

ALL of the following

Service is medically necessary
Member is eligible under plan (Medicaid excluding EFP, INTEGRITY, or Commercial)
Age-based screening frequency
- Women age 40–44: option to start annual screening mammogram
- Women age 45–54: annual mammogram
- Women age 55 and older: mammogram every 2 years or continue yearly; continue screening while in good health and expected to live at least 10 more years
High-risk or recent breast cancer exceptions allowing up to two screening mammograms per year
- Women treated for breast cancer within the last 5 years: up to 2 screening mammograms per year when recommended by a physician
- Women at high risk due to genetic predisposition (BRCA mutation or multiple first-degree relatives): up to 2 screening mammograms per year when recommended by a physician
- High risk lesion on prior biopsy (lobular carcinoma in situ): up to 2 screening mammograms per year when recommended by a physician
- Atypical ductal hyperplasia: up to 2 screening mammograms per year when recommended by a physician

CPT / HCPCS codes

Screening / Diagnostic Mammography Codes (included in policy)CPT

77063	Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure).
77067	Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed.
77065	Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral.
77066	Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral.

Coding guidance: Use the listed CPT/HCPCS mammography codes for screening versus diagnostic services as described — e.g., 77067 for screening bilateral 2-view mammography (includes computer-aided detection when performed) and 77063 for screening digital breast tomosynthesis (bilateral, list separately in addition to the primary procedure); diagnostic mammography codes 77065 (unilateral) and 77066 (bilateral) include computer-aided detection when performed. Follow standard CPT/ICD-10-CM/HCPCS coding rules and contractual billing requirements when submitting claims.

Billing, documentation, and authorization requirements

Documentation Required

Maintain records supporting medical necessity

Providers must maintain medical records supporting services billed and medical necessity; Neighborhood may request medical records and follows CMS standards for documentation.

Follows CMS standards for documentation

Billing Rule

Submit claims within timely filing guidelines

Providers are required to submit complete claims for payment within contractually determined timely filing guidelines and must use appropriate CPT/ICD-10-CM/HCPCS coding standards.

Prior Authorization

Verify prior authorization and eligibility

Providers must verify eligibility, coverage and authorization criteria prior to rendering services and refer to Neighborhood's plan-specific Prior Authorization Reference page for authorization requirements.

Refer to Neighborhood's plan-specific Prior Authorization Reference page

Document history

01/01/2023revisedLatest

Annual Policy Review Date. (Non-material)

11/30/2021revised

Policy Review Date. (Non-material)

10/21/2021revised

Content and format updates. (Non-material)

09/01/2013revised

Format change, minor edits. (Non-material)

09/01/2010added

Policy Effective Date. (Non-material)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMammography Screening Payment Policy 01.01.23

Policy CodePolicy N/A

Change TypeAnnual reviews and minor content/format updates

Effective DateSep 1, 2010

Next Review Date

Key ActionProviders must maintain medical records supporting services billed and medical necessity; Neighborhood may request records and follows CMS documentation standards.

SourceLink

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Mammography Screening Payment Policy 01.01.23

Policy summary

Medical necessity and coverage criteria

CPT / HCPCS codes

Billing, documentation, and authorization requirements

Key terms

Document history