Special Reimbursement Issue
Cancer care in general and breast cancer care in particular, is expensive and complicated. The current NCBC Bulletin contains important timely articles addressing detailed billing data regarding image guided breast biopsies and breast imaging, both of which are vitally important for NCBC Centers. In the breast image guided biopsy and billing article by Dr. Gary Levine, President of NCBC, and Director of MemorialCare Breast Center System, Fountain Valley, CA, we are provided with detailed information to help guide NCBC Centers in optimizing billing for biopsy procedures. In the other article by Mr. Gerald Kolb, President of the Breast Group, comprehensive breast imaging billing and coding is reviewed.
Dr. Levine gives us a comprehensive review of various Minimally Invasive Breast Biopsy (MIBB) procedures employing stereotactic, ultrasound, and MRI guidance. He provides detailed CPT codes and reimbursement figures. His article should be an invaluable resource for NCBC Breast Centers to refer to for billing and collection in 2015. We also learn that the Centers for Medicare and Medicaid Services (CMS) increased reimbursement by 50% for these procedures in 2015 compared to 2014 when performed in a Hospital Outpatient setting. This development occurred following a reduction in reimbursement in 2014. The subsequent increase occurred as a result of the efforts of many physicians, vendors, and organizations, including NCBC. The major concern which was raised to CMS was that the decreased reimbursement of MIBB would drive breast biopsies back to the operating room, thereby adversely affecting patient care. It is important to remember the positive impact that organizations like the NCBC made in reversing this CMS decision. As history has shown us repeatedly, and this recent MIBB story reinforces, there will be such issues and need for patient care advocacy in the future. Dr. Levine concludes his article by emphasizing the importance of remembering that Medicare claims data from 2014 and 2015 will impact future reimbursement. Therefore, Breast Centers must focus on accurate and complete billing in order to sustain the successes in increased reimbursement.
Mr. Kolb provides us a detailed review of 2015 CPT coding and billing for 2-D and 3-D Mammography, Breast Ultrasound, MRI, DEXA and Digital Breast Tomosynthesis (DBT). He also gives us a history of reductions and gains in reimbursement. While reimbursement decreased for MRI, new codes were developed for Breast Ultrasound and DBT. He concludes that the overall outlook for 2015 breast imaging is good. Both Dr. Levine’s and Mr. Kolb’s articles provide concise comprehensive data for Breast Centers to use in guidance for coding and billing for multiple breast imaging and biopsy procedures. In addition, we are reminded of the importance in participating in the process of disseminating information about the vital contribution that such procedures make in detecting breast lesions which in turn leads to early breast cancer diagnosis, breast preservation, and improved survival.
We are most grateful to Dr. Levine and Mr. Kolb for providing these important articles. The NCBC Annual Conference will be held March 14-18th in Las Vegas. We would like to thank all of the vendors who so faithfully support the cause of supporting NCBC, and in turn fighting breast cancer. We hope to see you all in Las Vegas for a great educational meeting and hopefully, a big fun time!
Rufus J. Mark, M.D.
rufusjmark@gmail.com
806-577-3741 (c)
MAKING SENSE OF THE BILLING/REIMBURSEMENT CHANGES RELATED TO PERCUTANEOUS MINIMALLY INVASIVE BREAST BIOPSY (MIBB)
Gary M. Levine, MD
In October, the U.S. Centers for Medicare and Medicaid (CMS) released the 2015 Hospital Outpatient Prospective Payment System (OPPS) Final Rule. It indicates that starting January 1, 2015, reimbursement rates for percutaneous breast biopsy procedures performed in a Hospital Outpatient setting will increase 50% over 2014 rates (see Table A below). This will restore reimbursement for minimally invasive breast biopsy (MIBB) in this setting to reasonable rates, in line with prior year’s rates for vacuum-assisted breast biopsy.
This is a very positive development for hospital based breast centers in an era when good news on Medicare reimbursement is rare. Recall that in 2014, reimbursement for the newly bundled percutaneous breast biopsy codes was drastically cut and severely undervalued. When the OPPS final rule was published in December 2013 it was apparent that CMS did not appropriately map the data from the predecessor code 19103 (vacuum-assisted biopsy code prior to 2014) into the new APC level assignment, thus severely under-valuing the new breast biopsy codes 19081, 19083 and 19085 for stereotactic, ultrasound and MRI guided biopsy respectively.
Individual physicians, vendors and breast care organizations (including NCBC) responded to CMS by relaying concerns that this severe undervaluation of MIBB was an error and would inevitably drive breast biopsy back to the operating room, adversely affecting care. Devicor Medical met with CMS in January 2014 requesting that this be corrected, successfully presenting to the Advisory Panel on Hospital Outpatient Payments with the same objective, and furthermore spearheading a congressional outreach campaign, together with clinicians and industry partners that generated multiple letters to CMS requesting they adhere to the Panel’s recommendations.
Percutaneous Breast Biopsies (Hospital Outpatient Setting)
As of January 1, 2014 the previously existing breast biopsy codes were deleted and the following codes created. 2014 and 2015 CMS Payments are listed.
Table A
| CODE DEFINITIONS | 2014 PAYMENT | 2015 PAYMENT |
| 19081 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance | $702.08 | $1052.22 |
| +19082 ... each additional lesion, including stereotactic guidance | $0. | $0. |
| 19083 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance | $702.08 | $1052.22 |
| +19084 ... each additional lesion, including ultrasound guidance | $0. | $0. |
| 19085 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance | $702.08 | $1052.22 |
| +19086 ... each additional lesion, including magnetic resonance guidance | $0. | $0. |
Note:
- Separate codes by modality (Xray, US, MRI).
- Reimbursement for MIBB is now independent of the imaging guidance utilized and the biopsy device chosen. Breast care clinicians will need therefore to thoughtfully manage their utilization of vacuum assisted biopsy devices, which are significantly more expensive than spring loaded tru-cut devices. However, the 2015 correction in reimbursement rate will allow one to select the optimal device for their patient’s clinical needs without financial constraint.
- Includes the use of imaging guidance – not coded separately
- Includes placement of a tissue marker/radioactive seeds (if performed)
- Includes specimen imaging (if performed)
- Biopsies from separate lesions should be coded in addition to the primary biopsy code, although they are packaged into the primary code as an add-on code. There is no technical payment for bx of a 2nd
- Post procedure mammograms are no longer bundled into the biopsy code when performed with MRI or ultrasound guidance. May also be appropriate to assign post procedure mammography when stereotactic guidance is used as long as the patient is moved to a separate dedicated mammography unit for the post procedure mammogram.
Office Based Setting
The improved reimbursement in 2015 for MIBB in the Hospital Outpatient Setting will unfortunately not be seen in the Office Based Setting.
Professional Reimbursement for MIBB
The reimbursement for professional services related to percutaneous breast biopsy unfortunately did not receive the same favorable adjustment that the technical reimbursement saw in the Hospital Outpatient setting. There are no specific provisions on the CY 2015 Proposed Medicare Physician Fee Schedule Rule, however adjustments required by the 5 yr review of malpractice RVU’s caused a slight reduction in the reimbursement for stereotactic and ultrasound guided breast biopsies but a slight increase in professional reimbursement for MRI guided biopsies (see Table B).
2015 Final Medicare Physician Fee Schedule (Pymt for Breast Bx)
| CPT Code | 2014 Physician Payment | 2015 Physician Payment | 2014-2015 Change | % Change |
| 19081(Stereo Bx) | $187.35 | $174.10 | ($13.25) | -7.07% |
| +19082(2nd Lesion) | $89.20 | $84.90 | ($4.30) | -4.82% |
| 19083(US Bx) | $175.53 | $171.23 | ($4.30) | -2.45% |
| +19084(2nd Lesion) | $83.83 | $79.88 | ($3.94) | -4.70% |
| 19085(MRI Bx) | $204.91 | $224.25 | $19.34 | 9.44% |
| +19086(2nd Lesion) | $91.35 | $97.08 | $5.73 | 6.27% |
Note:
- Although there is no technical reimbursement for bx of a 2nd lesion, there is professional reimbursement which is at ½ that of the 1st
- Anticipates a -20.9% update due to the sustainable growth rate formula following expiration of the Protecting Access to Medicare Act on April 1, 2015 unless there is congressional intervention.
- Continues implementation of the value-based payment modifier (VBPM) by applying the 2017 VBPM to solo practitioners and all physicians and non-physician eligible professionals (EPs) in groups with two or more EPs. CMS increases the maximum amount of payment risk under the VBPM from 2% in 2016 to 4% in 2017. The 2017 VBPM is based on 2015 performance.
- Outlines criteria for avoiding 2017 Physician Quality Reporting System (PQRS) penalties, which will be based on 2015 performance. CMS states that the criteria to avoid the 2017 penalty with 2015 reporting would be similar to the criteria for the 2014 bonus payment. Those criteria are at least 9 measures in three national quality strategy domains.
The Future:
It is very important to recognize that Medicare claims data generated in 2014 and 2015 will impact reimbursement in future years. This includes guidance on documenting accurate cost and charge data as well as examining the revenue codes that are assigned to these procedures. Both impact the ultimate data set that CMS examines to set future rates. A historical analysis of hospital based breast center data conducted by the Moran company shows that documented charges varied greatly and frequently undervalued breast biopsy procedures. All breast centers must be diligent in submitting accurate and complete billings in order to protect the gains achieved.
Resources:
CMS Hospital Outpatient Prospective Payment System
Breast Imaging in 2015
The Reimbursement Picture
Gerald R. Kolb, JD
When CMS released the Final Rule for 2015 the big news was, of course, the reimbursement for digital breast tomosynthesis and for ultrasound. But there was other news in the reimbursement information that will affect the financial picture for breast centers at least in the upcoming year. This paper will first outline the major changes, followed by a discussion of how volumes of the respective procedures will drive bottom line performance.
Rather than review the changes by cpt™ code, the material that follows reviews the impact of the 2015 Final Rule in terms of the procedure bundles that are actually utilized in the delivery of care to patients. As an example, a screening mammogram will typically include the mammogram itself (cpt™ G0202), plus the CAD add-on (cpt™ 77052), and new for 2015 an add-on code for digital breast tomosynthesis (DBT) (cpt™ 77063), if DBT is utilized. It is also important to pay attention to where the change occurs technical or professional fee as the changes to reimbursement are not always proportional.
Winners
Table 1 provides insight into each of the procedure bundles where the reimbursement is increasing in 2015 by more than 5% for either the global or professional fees. Each of the codes that show significant increases for 2015 are new codes that refine reimbursement for new technologies or applications of technology. This refers, of course, to the new and highly publicized add-on code for DBT, but perhaps the more important action was the recognition in coding methodology that breast ultrasound was not simply technology usable in a supporting diagnostic role, but, that improvements in ultrasound and the gathering weight of medical evidence had expanded the clinical role for breast ultrasound.
Both the DBT codes and the new ultrasound codes are new in their approach to coding, as well as in their codes. The DBT codes (77063 and G0279) are add-on codes utilized to reflect the addition of 3D to 2D screening and diagnostic studies, respectively. The two new ultrasound codes (76641, 76642), on the other hand, split the application of ultrasound to the breast into complete examination of the breast, and partial or more focused examination. The complete examination (76641) has particular application to screening breast ultrasound, while the partial code (76642) addresses focused diagnostic use of ultrasound. It is important to also note that both of these codes are unilateral. CMS has announced that when bilateral procedures are performed a multiplier of 150% should be applied, and indicated that a modifier would be provided for that purpose. Even the unilateral complete ultrasound reimburses higher than in 2014.
| Table 1 — 2015 Codes with Valuation Increases Greater than 5% | |||||||
| Cpt™ | Mod | 2015 | 2014 | Incr | % | ||
| Breast Ultrasound, complete, bilateral (1)(2) | 76641 | $162.28 | $99.23 | $63.05 | 63.54% | ||
| -TC | $107.47 | $71.65 | $35.82 | 50.00% | |||
| -26 | $54.81 | $27.58 | $27.23 | 98.70% | |||
| Bilateral 3D Diagnostic Mammogram | G0206, G0279, 77052 | $230.40 | $164.43 | $66.27 | 40.31% | ||
| -TC | $151.89 | $116.42 | $35.46 | 22.30% | |||
| -26 | $78.81 | $48.00 | $30.81 | 79.63% | |||
| Unilateral 3D Diagnostic Mammogram | G0206, G0279, 77052 | $195.23 | $141.50 | $65.56 | 37.97% | ||
| -TC | $125.74 | $102.81 | $22.93 | 22.30% | |||
| -26 | $69.50 | $38.89 | $30.81 | 79.63% | |||
| Screening Mammography, 3D | G0202, 77063. 77052 | $202.04 | $146.87 | $55.17 | 37.56% | ||
| -TC | $132.54 | $108.18 | $24.36 | 22.52% | |||
| -26 | $69.50 | $38.69 | $30.81 | 79.63% | |||
| Breast Ultrasound, partial, bilateral (1)(2) | 76642 | $133.26 | $99.23 | $34.03 | 34.30% | ||
| -TC | $82.21 | $71.65 | $10.57 | 14.75% | |||
| -26 | $51.02 | $27.58 | $23.46 | 85.06% | |||
| Breast Ultrasound, complete, unilateral (2) | 76641 | $108.18 | $99.23 | $8.90 | 9.03% | ||
| -TC | $71.65 | $71.65 | $0.00 | 0.00% | |||
| -26 | $36.54 | $27.58 | $8.96 | 32.47% | |||
| (1) Bilateral modifier 150% of unilateral | |||||||
| (2) Code replaces 76645 | |||||||
Losers
Against the upbeat news of new codes to be utilized in breast imaging, a number of codes commonly utilized in breast imaging suffered significant reductions. Table 2 is the counterpoint to Table 1. The most obvious changes are to breast MRI, both bilateral and unilateral. Interestingly, the codes now actually pay the same global fee and although having the same technical component might be justifiable, it is difficult to reconcile a higher technical component or equivalent professional fees for the unilateral procedure. One might surmise that CMS is actively trying either to enforce high utilization rates for each MRI unit, or to discourage the use of MRI altogether.
Although DEXA is not a breast imaging procedure, it is often offered in breast centers. This most recent decrease in reimbursement for DEXA from a high of $97.51 in 2011 makes the procedure unsustainable from an economic perspective. The reduction for unilateral partial breast ultrasound (76642) simply reflects the fact that there has only been a single code for breast ultrasound in the past, resulting in a disproportionately large payment when only one breast was examined. It should also be noted that even when only one breast is the subject of interest, it is often the practice to examine the same region in the contralateral breast for comparison.
| Table 2 — 2015 Codes with Valuation Decreases Greater than 5% | |||||||
| Cpt™ | Mod | 2015 | 2014 | Decr | % | ||
| Bilateral Breast MRI | 77059 | $543.79 | $834.39 | -$360.38 | -40.10% | ||
| -TC | $455.31 | $816.40 | -$361.09 | -44.23% | |||
| -26 | $83.11 | $82.39 | $0.72 | 0.87% | |||
| Unilateral Breast MRE | 77058 | $543.79 | $834.31 | -$290.52 | -34.82% | ||
| -TC | $460.68 | $751.92 | -$291.24 | -38.73% | |||
| -26 | $83.11 | $82.39 | $0.72 | 0.87% | |||
| DEXA | 77080 | $40.48 | $48.72 | -$8.24 | -16.91% | ||
| -TC | $30.39 | $38.69 | -$8.60 | -21.22% | |||
| -26 | $10.39 | $10.03 | $34.03 | 0.04% | |||
| Unilateral Breast Ultrasound, partial (1) | 76642 | $88.84 | $99.23 | -$10.39 | -10.47% | ||
| -TC | $54.81 | $71.65 | -$16.84 | -23.50% | |||
| -26 | $34.08 | $27.58 | $6.45 | 23.36% | |||
| Placement of Needle Localization, US guidance (2) | 19285 | $453.52 | $489.70 | -$36.18 | -7.39% | ||
| (1) Code replaces 76645 | |||||||
| (2) Payment was disproportionately high in 2014 and remains excellent in 2015. | |||||||
If one restricts their examination of both Table 1 and Table 2 to the physician fee (-26), an interesting fact emerges. Every one of the codes identified even overall decreases of up to 40% provide an increase in the physician fee. The reductions have all come on the technical side of reimbursement. Notwithstanding this fact, a close look at Table 1 also indicates that physicians were the “winners” in the codes that performed the best, providing very substantial increases for the physician fee, often significantly in excess of the technical increase.
Relative Impact
The final review of the 2015 codes should be done based on their relative utilization within a specific center or practice. If, for example, a practice has replaced all of its mammography units with 3D mammography, the addition of the 3D codes for screening and diagnosis will provide a significant increase in revenue. On the other hand, if a practice is predominately 2D digital units, it will not realize the gains in revenue that the fully 3D center will realize albeit at a high capital cost. The operative factor with ultrasound is using ultrasound for screening. While all centers will benefit from the new, higher payment rates, practices that approach screening aggressively will benefit accordingly from the volumes available for screening ultrasound (e.g., 40%+ of screening mammography population).
Conclusion
The outlook for breast imaging in 2015 is good! While breast MRI has taken a major hit, the addition of codes that improve reimbursement for the highest volume breast imaging procedures. The natural impact of this movement is positive, but special efforts to improve screening volumes both mammography and ultrasound will be rewarding both clinically and financially. The reimbursement message for 2015 is one of urgency. New codes are typically relatively free from meddling for a few years, as data is accumulated. Wise centers and practices will use this period to develop high volumes and tune workflow that optimizes efficiency for this changing world called healthcare.
Gerald Kolb is the president of the Breast Group, a consulting firm specializing in optimizing workflow in breast centers and practices that specialize in the detection and diagnosis of breast disease. A recent focus of effort has been the integration of new technologies into breast practices. Kolb has over 20-years of experience working with breast centers, and is a regular presenter at national meetings as well as the author of more than 50 published articles. He can be reached at gerald.kolb@breastgroup.com, or by calling 303-881-1012.