Dense Breast Claim Denials for Covered Codes US – Industry News, May 2023

Claim Denials for Covered Codes for Dense Breast US

Claim denials for breast ultrasounds for patients with dense breasts triggered a Targeted Probe and Educate (TPE) for one Medicare Administrative Contractor (MAC) to ensure compliance when policy indicated covered diagnoses does not support payment.

Medicare does not routinely cover breast screening ultrasounds unless they are supported as medically necessary. The diagnosis of dense breasts does not necessarily immediately qualify medical necessity support for the testing. However, within National Government Services’ (NGS’) local coverage determination (LCD), dense breasts are listed as a covered diagnosis. To add to the confusion surrounding coverage, some states, such as Illinois have laws indicating coverage of breast ultrasound screening if a mammogram demonstrates dense breast tissue, when medically necessary. Many times, physicians and beneficiaries do not realize Medicare supersedes state law.

In an attempt to reduce confusion, NGS outlines coverage and billing guidance for breast ultrasound on their website. NGS explicitly states that ultrasound should not be routinely with diagnostic mammography and in order for a breast ultrasound to be covered, it must be diagnostic in nature and not for screening purposes. NGS also highlights the importance that dense breast tissue alone does not constitute medical necessity, but an ultrasound may be indicated if breast density interferes with the ability to diagnose abnormal findings on mammography.

NGS advises a detailed Advance Beneficiary Notice of Noncoverage (ABN) should be issued to the beneficiary if there is concern or anticipation of noncoverage for the breast ultrasound.

CMS Price Transparency Crack Down

The Centers for Medicare and Medicaid Services (CMS) has increased enforcement of the price transparency rule by handing down fines and releasing names of hospitals which are not in compliance.

CMS has updated their enforcement policy to make certain every hospital complies with the price transparency requirements. The following areas, which do not require rulemaking, have been updated:

  1. Requiring corrective action plan (CAP) completion deadlines.

    CMS will continue to require hospitals that are out of compliance with the hospital price transparency regulation to submit a CAP within 45 days from when CMS issues the CAP request. CMS will also now require hospitals to be in full compliance with the hospital price transparency regulation within 90 days from when CMS issues the CAP request, rather than allowing hospitals to propose a completion date for CMS approval which can vary. This change will standardize and streamline the timeframe and promote compliance at earlier dates.

  2. Imposing civil monetary penalties (CMPs) earlier and automatically.

    Currently, CMS does not impose automatic CMPs for failure to submit a requested CAP or failure to come into compliance within 90 days from when a CAP request is issued. CMS will now automatically impose a CMP on hospitals that fail to submit a CAP at the end of the 45-day CAP submission deadline. Before imposing the CMP, CMS will re-review the hospital’s files to determine whether any of the violations cited in the CAP request continue to exist and, if violations are found, impose a CMP. For hospitals that submit a CAP by the 45-day CAP submission deadline but fail to comply with the terms of that CAP by the end of the 90-day deadline, CMS will re-review the hospital’s files to determine whether any of the violations cited in the CAP request continue to exist and, if so, impose an automatic CMP.

  3. Streamlining the compliance process.
    For hospitals that have not made any attempt to satisfy the requirements (i.e., those that have not posted any machine-readable file or shoppable services list/price estimator tool), CMS will no longer issue a warning notice to the hospital and will instead immediately request that the hospital submit a CAP. Currently, CMS does not issue CAP requests without first issuing a warning notice.

CMS has leveraged automation to complete hospital reviews increasing comprehensive reviews conducted from 30-40 per month to 200 per month. As of April 2023, CMS has issued over 730 warning notices and 269 requests for CAPs. CMS has also imposed CMPs on four hospitals and listed their names on the CMS website for noncompliance.

New Breast Cancer Screening Guidelines from ACR, USPSTF

The American College of Radiology ® (ACR®) has released new breast cancer screening guidelines to include the recommendation that certain women demographics initiate risk assessment as early as age 25. the U.S. Preventive Services Task Force (USPSTF) is planning on lowering their breast cancer screening age guideline from 50 to 40 for women of average risk.

Within the new breast cancer screening guidelines, starting at age 25, it is recommended Black and Ashkenazi Jewish women should have a risk assessment to determine if screening earlier than age 40 is needed. While the ACR continues to recommend women at average risk start annual screening at age 40, they are emphasizing earlier and more intensive screening for high-risk patients.

Updates within the revised breast cancer screening guidelines include:

  • Women with genetics-based increased risk (including BRCA1 carriers), those with a calculated lifetime risk of 20% or more and those exposed to chest radiation at a young age are recommended to have MRI surveillance starting at ages 25 to 30. These women should start annual mammography at ages 25 to 40, depending on type of risk.
  • Women diagnosed with breast cancer prior to age 50 or with personal history of breast cancer and dense breasts should have annual supplemental breast MRI.
  • High-risk women who desire supplemental screening — but cannot undergo MRI screening — should consider contrast-enhanced mammography (CEM).

Additionally, the ACR released their guidelines for screening for women at higher-than-risk in May 2023 within the Journal of the American College of Radiology (JACR). The ACR recommends annual digital mammography, beginning between ages 25-40, as well as supplemental breast MRI screening for women at higher-than-average risk.

“The latest scientific evidence continues to point to earlier assessment as well as augmented and earlier-than-age-40 screening of many women — particularly Black women and other minority women,” said Debra Monticciolo, MD, FACR, primary author of the new guidelines and division chief, Breast Imaging, Massachusetts General Hospital, Boston. “These evidence-based updates should spur more-informed doctor-patient conversations and help providers save more lives.”

While ACR maintains their recommendations for annual screening at age 40 for average risk women, the U.S. Preventive Services Task Force (USPSTF) is planning on lowering them breast cancer screening age from 50 to 40 for women of average risk. The current USPSTF guidelines recommends a screening mammography every other year starting at age 50. The newly drafted recommendation plans to lower the biennial screening to start at age 40.

According to the USPSTF, “new and more inclusive science about breast cancer in people younger than 50 has enabled us to expand our prior recommendation and encourage all women to get screened in their 40s. We have long known that screening for breast cancer saves lives, and the science now supports all women getting screened, every other year, starting at age 40.”

Cigna’s Modifier 25 Policy Change Delayed

After notifying providers of a significant change when billing Evaluation and Management (E/M) claims with modifier 25 in 2022, Cigna received substantial opposition from physicians, health care professionals, and other stakeholders which resulted in a delayed implementation of the policy. Cigna re-released its controversial policy for implementation on May 25, 2023, again receiving significant pushback resulting in an additional delay.

Modifier 25, significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service, is utilized to identify when distinct services are performed on the same day, as outlined by the American Medical Association (AMA) within their “Reporting CPT Modifier 25” article.

Cigna’s delayed modifier 25 policy would require submission of office notes with ALL claims which include E/M codes 99212, 99213, 99214, 99215, and modifier 25 when a minor procedure is billed. Failure to submit office notes in these circumstances would result in a denial of payment. Complaints submitted to Cigna cited the significant negative impact on administrative burden and costs as well as the potential negative impact on patients receiving timely care.

As currently stated on their Modifier 25 Reimbursement Policy, “Cigna will delay the implementation to require the submission of documentation to support the use of modifier 25 when billed with E/M CPT® codes 99212-99215 and a minor procedure. Cigna will continue to review for future implementation.”

Cigna directs the use of for the most up-to-date information regarding their medical policy updates.

TPE for Avastin® Review Results

Palmetto GBA has released their pre-payment target probe and educate (TPE) review results for Avastin® (Bevacizumab) for January through March 2023.

Palmetto has reported, out of 278 claims reviewed for North and South Carolina, Virginia, and West Virginia, a total of seven, or 3%, were denied totaling $16,017.03. This classifies Healthcare Common Procedure Coding System (HCPCS) code J9035 as a minor risk. However, of the claims denied, 50% were due to requested records not being submitted in a timely manner.

Palmetto reminds providers that they have 45 days from the date the Additional Documentation Request (ADR) is generated to respond with medical record submission. Additionally, Palmetto advises if it’s less than 120 days after the denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original ADR to request reopening; do not resubmit the claim.