Wiki coding when not the performing facility

[BarbaraCotton2023]

We recently started doing the billing for a large group of internal medicine physicians. They have been coding the breast cancer screening as 77067 (breast mammography). They are not the performing facility. It is my understanding they should be receiving the mammography results from the performing facility, uploading the report to the payer and only coding the level ll codes per the results (example: 3014f - Screening mammography results documented and reviewed), NOT the 77067 cpt. I am getting push back from the providers who say they have always billed with 77067 to meet /close the measure. The physicians believe it is permissible because they charge $0. However, they are trying to attain goals for incentive payments. Can anyone clarify? Thanks!

 

[sls314]

We recently started doing the billing for a large group of internal medicine physicians. They have been coding the breast cancer screening as 77067 (breast mammography). They are not the performing facility. It is my understanding they should be receiving the mammography results from the performing facility, uploading the report to the payer and only coding the level ll codes per the results (example: 3014f - Screening mammography results documented and reviewed), NOT the 77067 cpt. I am getting push back from the providers who say they have always billed with 77067 to meet /close the measure. The physicians believe it is permissible because they charge $0. However, they are trying to attain goals for incentive payments. Can anyone clarify? Thanks!

No, they should absolutely not be using the 77067 code. They are not performing or reading the mammogram.

This could also be affecting the patient's benefits and/or other provider's claims. If they are billing the 77067, the provider billing the technical or professional component may get push back on their claims.

If the patient has a benefit for 1 screening mammogram every 12 months, your provider billing the 77067 could cause the actual screening mammogram claim to get denied for exceeding the benefit level.