UPDATE: Following the interview featured in this article, the Centers for Medicare & Medicaid Services issued a correction to the 2015 MPFS Final Rule that affects the new tomosynthesis code. Providers who perform diagnostic digital breast tomosynthesis without performing accompanying 2D mammography are being asked to still code for both procedures. Click here for more details.

Digital breast tomosynthesis scored a win on Oct. 31, 2014, when the Centers for Medicare and Medicaid Services (CMS) approved Medicare reimbursement for women undergoing a tomosynthesis exam in conjunction with 2D digital mammography.

The green light for digital breast tomosynthesis may pave the way for additional changes in breast imaging reimbursement. Private payers could follow suit. And reimbursement enables researchers to delve into unanswered questions about the technology. Specifically, which patients are most likely to benefit from the 3D breast imaging technology?

The breast screening add-on code, 77063, screening digital breast tomosynthesis, bilateral, went into effect Jan. 1, 2015, and is to be used with the digital screening mammography code G0202 for Medicare patients. The payment rate is approximately $57. Although the CPT panel created two additional codes 77061 and 77062 for diagnostic digital breast tomosynthesis, CMS determined that these codes are not valid for Medicare purposes. Instead, practices need to use an add-on G-code (G0279) when tomosynthesis is performed as an add-on to a diagnostic exam. The payment rate for G0279 also is approximately $57.

To understand the larger implications of the CMS decision, Health Imaging spoke with Geraldine McGinty, MD, MBA, assistant professor of radiology at Weill Cornell Medical College in New York City and chair of the American College of Radiology (ACR) Commission on Economics.

Digital breast tomosynthesis technology has been on the market since February 2011, but there has not been reimbursement for the exam, which can be performed as an add-on to a 2D digital screening or diagnostic mammogram. How might reimbursement impact dissemination of tomosynthesis technology?

McGinty:  Having Medicare reimbursement for breast tomosynthesis is certainly a positive factor in terms of adoption of the technology. There are practices that have made the investment in tomosynthesis without definitive reimbursement.

However, we can’t expect all radiology practices to do that. It’s difficult to justify investing in a piece of equipment with no reimbursement. I anticipate that the availability of reimbursement for tomosynthesis will be a positive factor in the decision to invest in the technology for some practices.

Is there a need to educate referring physicians and patients about the availability of Medicare reimbursement for digital breast tomosynthesis exams?

McGinty: Education is going to be an evolving process that varies by practice. Most practices that have had tomosynthesis technology have already started having conversations with referring physicians and patients.

But practices that make the decision to upgrade to breast tomosynthesis will need to educate the referring physician community and patients about the technology.

Are private payers likely to follow CMS’ lead and begin reimbursing for tomosynthesis?

McGinty: How private payers will respond is a bit of an unknown. There has been some anecdotal information that suggests some private insurers still see tomosynthesis as experimental and aren’t going to reimburse for the exam.

Until this point, practices have been able to bill private payer patients for tomosynthesis. But this isn’t an optimal approach.

The American College of Radiology plans to engage with the private payer community and encourage them to cover it now that CMS has announced its decision.

Radiology practices that provide tomosynthesis exams should check with private payers to determine how they plan to handle reimbursement when tomosynthesis is used as part of the screening exam and also if they plan to recognize the CPT codes (77061 and 77062) for diagnostic tomosynthesis or if they will recognize the G-code (G0279).

Are there differences in coding between Medicare and private payers?

McGinty: In 2015, Medicare Administrative Contractors will pay for the combination of mammography and tomosynthesis using G-codes for mammography and the add-on codes for tomosynthesis. If a Medicare patient has a tomosynthesis exam without a mammogram, the radiology practice needs to use an unlisted radiology code (76499).

Private payers may use the G-codes in combination with the add-on tomosynthesis codes approach or the newly created CPT codes. When a private patient undergoes a tomosynthesis exam without a mammogram the payer can use CPT codes 77061 and 77062 for accurate coding and payment.

How does the CMS decision impact clinical research?

McGinty: The ACR’s position on tomosynthesis is that it is a very promising technology. The evidence suggests that it reduces additional imaging and may improve cancer detection in some women. The ACR is very focused on using imaging technology as effectively and as appropriately as possible, so we need further research to determine which women tomosynthesis is most helpful for.

We need payers to reimburse for tomosynthesis to facilitate the outcomes research and gather the data.

What’s on the horizon as far as breast imaging coding and reimbursement?

McGinty: Breast imaging codes had been up in the air until we got the final Medicare Rule on October 31, 2014. We thought that the perhaps G codes were going away, so we had to have scenarios around that. Now, the G codes are not going away, but they potentially could go away in the future. We’ll continue to do scenario planning regarding the best approach to preserving access for this life saving service.

CMS also plans to re-visit payment for tomosynthesis and planar mammography as part of a review under its misvalued codes initiative. [Under this initiative, CMS conducts an evaluation of potentially misvalued codes, and if it determines the code is misvalued, CMS will update and revise payment for the exam. In addition, when the Relative Value Scale Update Committee (RUC) reviews the mammography family, CMS plans to re-evaluate the relative value units (RVUs) and payment amounts, for CPT codes 77061 and 77062.]