Independent healthcare providers are concerned about ultrasound reimbursement for supplemental breast screening, particularly for women with dense breast tissue. Although 38 states now have legislation in place requiring mammography providers to notify patients if they have dense breasts, many women are unsure of what to do with this information.
A University of Virginia School of Medicine study found that "most women" do not understand what having dense breasts means for them — whether it increases their risk of cancer or how mammograms may not be able to visualize cancers that could be hidden within the dense tissue that appears white on mammograms.
Women with increased risk may need additional screening to rule out breast cancer. Many gynecologists are opting for automated breast ultrasound (ABUS), which uses a larger ultrasound transducer to image the breast. However, insurance may not cover this procedure.
How Private Insurance Affects Breast Screenings
According to the Kaiser Family Foundation (KFF), the Affordable Care Act requires that private health insurance cover mammograms "at no cost to the consumer" every one to two years for women ages 40 and older who have an average breast cancer risk. The law does not address additional screening services for women at higher risk. The KFF analyzed data from the U.S. Centers for Disease Control and Prevention to determine that among uninsured women, only about 30 percent reported having a mammogram within the past two years, while mammograms among women with private insurance reached 72 percent.
As recently as 2019, Diagnostic Imaging (DI) reported that Medicare will cover ABUS imaging if "medically indicated," but also that many private insurers do not cover the cost of this particular scan. DI and other sources speak to the benefits of ABUS over traditional ultrasound and even 3D mammograms. ABUS has been praised for image reproducibility, reducing the variability between operators and reducing human error.
Breast image using ABUS
How to Bill for ABUS
Though ABUS may not be necessary or appropriate for all women, it is a noninvasive, efficient way to image dense breasts. Although mammograms are almost always covered by insurance at no cost to the patient, additional screenings such as ABUS, which are recommended by the American Cancer Society for women with increased risk, may be subject to co-pays or co-insurance payments.
If you would like to recommend ABUS screening to a patient, first have that patient check with their insurance company to see whether the service is covered and what the out-of-pocket costs might be.
Some states currently mandate coverage for supplemental screening (Arkansas, Illinois, Indiana, New York, Vermont, Connecticut and New Jersey), but outside those states, private insurance may or may not provide ultrasound reimbursement for ABUS. When your patients call their insurance providers, they should give 76641 as the procedure code. If the insurance company says they will not cover ABUS, both you, as the physician, and the patient can appeal the decision. ABUS is also more cost-effective than other alternative screenings, such as MRI, so it is likely that some women would be willing to cover the cost of this procedure out of pocket for peace of mind.
Using the 76641 CPT code, independent providers are able to be reimbursed for unilateral scans for technical, professional and global payments of $71.82, $37.17 and $108.99, respectively. The modifiers for the CPT code are 26 for professional, 50 for bilateral and TC for technical component. As always, the procedure should be documented with a written summary within the medical record, and the ICD-10-CM or ICD-10-PCS code should reflect that the procedure was necessary based on mammogram findings.
Although breast density reporting has been making the news over the past several years, it is clear that many patients need guidance on what to do with this information. Be sure to talk to your patients who have dense breast tissue. Make sure they understand their cancer screening needs, and the importance of an additional screening tool beyond their annual mammogram and self-exams. With careful planning and billing, these supplemental screenings may be reimbursed.
