Mammography remains one of the most critical areas of radiology practice, and one that is facing changes in reporting requirements and reimbursement policy. Even with additional mammography reporting requirements placed on radiology practices, the reimbursement value of mammography services has not changed to reflect the extra work. However, changes to screening policy could provide increased mammography volume.
New Reporting Requirements
In March 2023, the FDA issued a Final Rule that went into effect on September 10, 2024, imposing certain specific reporting requirements for mammography results, along with some other quality control measures. The new reporting requirements that are incorporated into the Mammography Quality Standards Act (MQSA) include:
- The addition of 3 new assessment categories in order to more precisely classify findings;
- A specific timeframe for reporting results when the findings are “Suspicious” or “Highly Suggestive of Malignancy”;
- A requirement to include an assessment of breast density. Specifically,
- Changing the wording to be “dense” or “not dense” rather than the high- or low-density phrasing in current use.
- The summary report provided to patients must include specific statements for dense or non-dense findings.
- The report provided to the patient’s healthcare provider must include an overall assessment of breast density using one of four specific categories.
Breast density assessment is important not only for the patient’s health, but it also has reimbursement implications for radiologists. Breast density can often obscure lesions on conventional x-ray mammography, and so other screening modalities such as MRI or ultrasound are often recommended for follow-up. Patients with dense breasts might also require more frequent screening due to their increased risk.
Considerations for Subsequent Imaging
Patients identified as having dense breasts are recommended for additional imaging using MRI, ultrasound, or contrast enhanced mammography. Contrast enhanced mammography (CEM) is faster and less costly than MRI and can often be used as a follow-up to an abnormal screening mammogram when it is clinically appropriate. For the CEM procedure a diagnostic mammogram is billed as usual along with the addition of a code for the contrast injection (96374), and also for the contrast itself (Q9967) when billing globally or for the technical component. Note that direct supervision is required for the contrast administration if it is not performed by the physician, and the normal precautions for patients with renal disease or iodine allergies apply. The diagnostic exam typically does not require any additional prior authorization following an abnormal screening exam, , whereas using MRI for the follow-up would often require authorization.
While most payers are required to cover traditional screening mammograms for patients who meet the coverage criteria at no out-of-pocket cost to the patient, additional imaging using other modalities might not be similarly covered. There is currently no federal requirement for zero out-of-pocket coverage, but some states have implemented regulations to cover additional imaging, including breast MRI and ultrasound. The status of state coverage is changing quickly, and up to date information can be found at the Dense Breast Info website.
At the federal level, the Find It Early Act (H.R. 3086) was introduced in May, 2023, and currently has 73 co-sponsors. It was referred to the House Subcommittee on Health on December 17, 2024. If passed, this bill would require all insurance payers (including Medicare) to cover screening and diagnostic breast imaging with no out-of-pocket costs for women with dense breasts or those who are at higher risk for breast cancer.
Revised Screening Recommendations
Radiology practices will benefit from updated recommendations for the initiation of breast cancer screening. In April 2024, the US Preventive Services Task Force (USPSTF) issued a final recommendation statement.
Previously, the USPSTF recommended “that women in their 40s make an individual decision with their clinician on when they should start screening, taking into account their health history, preferences, and how they value the different potential benefits and harms. The Task Force now recommends that all women start getting screened for breast cancer every other year starting at age 40. Basically, it’s a shift from recommending women start screening between the ages of 40 and 50 to recommending that all women start getting screened when they turn 40.”
This is a Grade B recommendation, which means that the Affordable Care Act (ACA) will require most private health insurance plans to cover the screening services without charging patients for deductibles, copayments, or coinsurance starting.
Conclusion
Adequate reimbursement for the level of care provided to patients in this critically important procedure continues to be a challenge. While screening is covered for most patients with no out-of-pocket cost, many need subsequent imaging that is often not fully covered or requires prior authorization that further complicates the overall evaluation process for the patient and radiology practice. We will continue to monitor reimbursement for mammography on both the federal and state level. Subscribe to this blog for more information.
Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.
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