Does 11 Really Mean 12? Breaking Down the Limitations on Mammogram Screening.

by Catherine Caldwell, Fotheringill & Wade, LLC

Continuing our series to honor Breast Cancer Awareness Month, in this post we will discuss ongoing denial issues relating to mammogram coverage under Medicare. While each claim is unique, similarities between claims and their denials can provide insight which can be used to prevent future denials. Below we will break down the CMS regulation which provides the parameters for coverage of mammography services for women (42 CFR 410.34(d)) and will present case studies which illustrate interpretation of the policy.

Breaking Down the Policy:

Mammograms are very important in the early detection and treatment of breast cancer. However, CMS policy places limitations on the circumstance under which Medicare will provide coverage for mammography screening. 42 CFR 410.34(d) states the following:

  •  “The service must be, at a minimum a two-view exposure (that is, a cranio-caudal and a medial lateral oblique view) of each breast.
  •  Payment may not be made for screening mammography performed on a woman under age 35.
  • Payment may be made for only 1 screening mammography performed on a woman over age 34, but under age 40.
  • For an asymptomatic woman over 39 years of age, payment may be made for a screening mammography performed after at least 11 months have passed following the month in which the last screening mammography was performed.”[1]

(DISCLAIMER: the regulations do allow for diagnostic mammograms. If a patient presents with symptoms that would warrant the need for a mammogram, the provider is allowed to perform a mammogram outside of the above mentioned situations. The regulations relating to be requirement for diagnostic mammograms can be found in 42 CFR 410.34 (b). Additionally, diagnostic mammograms are available for men who are covered by Medicare.)[2]

 The Limitations

 Subsection 2

This subsection states a concrete rule. NO PAYMENT will be made for mammograms if the patient is under 35 years old. This should be an automatic red flag for all providers. Unless the patient has additional coverage through another insurer (Medicaid or Commercial), there will be no payment made by an insurer.

Subsection 3

This subsection indicates that payment MAY be issued for a mammogram performed on a patient who is over the age of 34 but younger than 40. Please note, this does not allow for an annual mammogram for patients in this age range. The regulation states that only ONE mammogram may be covered for women in this age bracket. As such, if you have a patient that falls within this qualification, it is extremely important to ask the patient if she has ever had another mammogram. Not asking this question runs a risk of an automatic denial.

Subsection 4

This subsection appears to cause the most issues for providers. At the first reading the subsection does not seem very complex. So then why do we see so many denials under this subsection? The issue becomes clearer if you look closely to the wording. What exactly does 11 months after the month from the last mammography mean? How does the claims processor count the months? A few case studies shed some light on how exactly the subsection is used to deny cases.

 

Case Studies

Study #1:

Denial Reason: Patient’s mammogram benefits for the year had been exhausted.

Case Facts: 79 years old woman covered by Medicare was seen for a mammogram on 6/30/14. The patient’s last mammogram screening was performed on 7/1/13.

Discussion: For those of you counting at home, 11 months from July 1 is typically June 1 of the next year. So, why was this claim denied? The denial comes down to the exact wording of the regulation. The regulation specifically states that coverage may be given for a mammogram performed after at least 11 months have passed following the month in which the last screening mammography was performed. The regulation is being interpreted as to require that the patient wait 11 months after the month in which they had their previous mammogram. In this case, the provider would have needed to count from 8/1/13 (the first of the month after the month in which the patient had her previous mammogram) making the patient’s mammogram due 7/1/4, just one day after the patient had her mammogram.

 Study #2:

Denial Reason: Patient’s mammogram benefits for the year had been exhausted.

Case Facts: 59 years old woman came to her provider for her annual mammogram on 07/01/14. The patient’s last mammogram screening was performed on 8/15/13.

Discussion: This case is a little easier to determine why the claim was denied. From date to date, there is only a 10 month gap between the mammograms. However, using the terminology of the regulation, the provider would have needed to count 11 months from 9/1/13. The mammogram was provided prior to expiration of the timeframe under the regulation.

 

Takeaways:

Though the provider is still fighting the denials on both of the above claims, these denials show that the timing for mammograms is key to safeguard the likelihood of payment. Providers should check their records to confirm when a patient had her last mammogram. If this is the patient’s first mammography visit to your office/hospital, it is imperative that the provider question the patient as to when her last mammogram was performed. Providers are also better served to err on the side of caution and calculate the 11 months starting the first day of the month after the previous mammogram. Although there is no guarantee of payment, taking steps to ensure that the claim is compliant with all of the applicable regulations can assist in faster payment.

 

[1] 42 CFR § 410.34(d) (1998).

[2] Id. Sub. Section (b).