BCCHP Allowable Reimbursement Schedule
Breast and Cervical Cancer Screening and Diagnosis
July 1, 2012 – June 30, 2013
CPT®
HCPCS
Modifier
EVALUATION AND MANAGEMENT PROCEDURES
Professional
Professional
Procedure Code Description
Non-Facility
Facility
OFFICE
PROVIDER
99201
Global
New patient-problem focused, straightforward 10 min
$
46.37
99202
Global
New patient expanded focused, straightforward 20 min
$
78.55
99203
Global
New patient detailed-low complexity 30 min
$
113.32
99204
Global
Office-new patient moderate complexity 45 min
$
171.89
99205
Global
Office-new patient high complexity 60 min
$
212.93
99211
Global
Established patient-problem focused, straightforward 5 min
$
21.77
99212
Global
Established patient- expanded focused, straightforward 10 min
$
43.82
99213
Global
Established patient-expanded focused, low complexity 15 min
$
76.05
CPT®
HCPCS
Modifier
PREVENTIVE MEDICINE PROCEDURES
Professional
Professional
Procedure Code Description
Non-Facility
Facility
OFFICE
PROVIDER
99386
Global
Preventive visit, new patient, 40-64
$
113.32
99387
Global
Preventive visit new patient, 65+
$
113.32
99396
Global
Preventive visit, established patient, 40-64
$
76.05
99397
Global
Preventive visit, established patient, 65+
$
76.05
CPT®
HCPCS
Modifier
ANESTHESIA PROCEDURES
Professional
Procedure Code Description
Non-Facility
OFFICE
Professional
Facility
PROVIDER
00400
Global
Anesthesia, anterior trunk procedure($250 max) [(Base Unit (3) +
Time Unit) x Conversion Factor (CF) = Fee
$
22.16 CF
00940
Global
Anesthesia, vaginal procedure ($250 max) [(Base Unit (3) + Time
Unit) x Conversion Factor (CF) = Fee
$
22.16 CF
For persons with disabilities, this document is available on request in other formats. To submit a request, call 1-800-525-0127, (711).
Hospital
Outpatient
Ambulatory
Surgery
Center
Lab
Hospital
Outpatient
Ambulatory
Surgery
Center
Lab
Hospital
Outpatient
Ambulatory
Surgery
Center
Lab
1
DOH 343-032 June 2012
BCCHP Allowable Reimbursement Schedule
Breast and Cervical Cancer Screening and Diagnosis
July 1, 2012 – June 30, 2013
CPT®
HCPCS
Modifier
BREAST AND CERVICAL CANCER SCREENING AND DIAGNOSTIC PROCEDURES
Professional
Hospital
Professional
Procedure Code Description
Non-Facility
Outpatient
Facility
PROVIDER FEE
OFFICE FEE
FACILITY FEE
ASC
FACILITY FEE
10021
Global
Fine needle aspiration without imaging
$
160.32
$
73.49
$
112.73
$
70.05
10022
Global
Fine needle aspiration with imaging
$
150.14
$
67.59
$
320.01
$
198.87
11100
Global
Skin Excision (Punch Biopsy)
$
114.50
$
52.20
$
104.86
$
65.16
Global
Add-on Skin Excision (Punch Biopsy)
$
145.12
$
145.12
$
145.12
$
145.12
Global
Puncture aspiration breast cyst without imaging
$
115.98
$
45.10
$
240.00
$
83.59
Global
Puncture aspiration breast cyst (add-on)
$
35.27
$
26.33
$
112.73
$
11.00
19030+
Global
Injection for ductogram/galactogram
$
176.34
$
80.16
19100
Global
Breast biopsy percutaneous without imaging
$
161.91
$
71.57
$
240.00
$
198.87
19101
Global
Breast biopsy open-incisional
$
367.19
$
231.69
$
1,784.21
$
1,108.77
19102
Global
Breast biopsy percutaneous with imaging
$
232.52
$
105.97
$
570.59
$
354.59
19103
Global
Breast biopsy percutaneous with device
$
608.06
$
197.65
$
1,073.79
$
667.29
19120
Global
Breast excision(s)-open
$
518.15
$
429.76
$
1,784.21
$
1,108.77
19125
Global
Breast excision- open radiological marker, single
$
573.87
$
476.52
$
1,784.21
$
1,108.77
Global
Breast excision-radiological marker (add-on)
$
165.51
$
165.51
$
1,784.21
$
1,108.77
Global
Pre-op placement of needle localization wire-breast
$
176.41
$
66.60
Bundled
Global
Pre-op placement needle localization wire-breast (add-on)
$
74.49
$
32.82
Bundled
19295
Global
Image guided placement clip percutaneous-breast biopsy
$
104.27
$
104.27
Bundled
57452
Global
Colposcopy- cervical
$
117.55
$
98.08
$
110.80
$
54.63
57454
Global
Colposcopy-cervical with biopsy and Endocervical Curettage (ECC)
$
165.11
$
165.11
$
243.80
$
68.19
57455
Global
Colposcopy-cervical with biopsy
$
154.87
$
117.87
$
243.80
$
71.12
57456
Global
Colposcopy-cervical with Endocervical Curettage (ECC)
$
146.66
$
110.05
$
243.80
$
68.55
57460
Global
Colposcopy-cervical with LEEP
$
318.34
$
174.26
$
1,444.21
$
193.20
57461
Global
Colposcopy cervical with LEEP conization
$
357.37
$
200.05
$
1,444.21
$
207.13
57500
Global
Cervical biopsy(ies)
$
143.26
$
81.35
$
472.66
$
89.82
57505
Global
Endocervical curettage
$
111.76
$
100.08
$
472.66
$
60.49
11101+
19000
19001 +
19126 +
19290
19291 +
For persons with disabilities, this document is available on request in other formats. To submit a request, call 1-800-525-0127, (711).
Lab Fee
Bundled
DOH 343-032 June 2012
2
BCCHP Allowable Reimbursement Schedule
Breast and Cervical Cancer Screening and Diagnosis
July 1, 2012 – June 30, 2013
CPT®
HCPCS
Modifier
BREAST AND CERVICAL CANCER SCREENING AND DIAGNOSTIC PROCEDURES
Professional
Professional
Procedure Code Description
Hospital
Non-Facility
Facility
Outpatient
OFFICE
PROVIDER
Ambulatory
Surgery
Center
57520
Global
Conization of cervix
$
332.39
$
293.84
$
1,444.21
$
897.48
57522
Global
Conization of cervix LEEP
$
285.56
$
262.58
$
1,444.21
$
897.48
58100
Global
Endometrial Biopsy (EMB)
$
118.81
$
93.50
$
110.80
$
54.26
Global
Endometrial Biopsy (EMB) with colposcopy (add-on)
$
51.49
$
43.31
$
130.15
Global
X-ray exam, breast specimen
$
20.59
$
20.59
Bundled
76098TC
TC
X-ray exam, breast specimen
$
12.37
$
12.37
7609826
26
X-ray exam, breast specimen
$
8.22
$
8.22
Global
Ultrasound (USN) breast(s)
$
99.77
$
99.77
$
39.10
76645TC
TC
Ultrasound (USN) breast(s)
$
71.95
$
71.95
7664526
26
Ultrasound (USN) breast(s)
$
27.83
$
27.83
Global
Ultrasound (USN) breast(s) real time with image documentation
$
233.20
$
233.20
76942TC
TC
Ultrasound (USN) breast(s) real time with image documentation
$
198.50
$
198.50
7694226
26
Ultrasound (USN) breast(s) real time with image documentation
$
34.70
$
34.70
Global
Stereotactic guide for breast biopsy
$
159.44
$
159.44
77031TC
TC
Stereotactic guide for breast biopsy
$
77.01
$
77.01
7703126
26
Stereotactic guide for breast biopsy
$
82.43
$
82.43
Global
Mammography guidance for needle, breast
$
59.29
$
59.29
77032TC
TC
Mammography guidance for needle, breast
$
30.67
$
30.67
7703226
26
Mammography guidance for needle, breast
$
28.61
$
28.61
Global
X-ray of mammary duct-single (ducto/galactogram)
$
71.18
$
71.18
77053TC
TC
X-ray of mammary duct-single (ducto/galactogram)
$
53.26
$
53.26
7705326
26
X-ray of mammary duct-single (ducto/galactogram)
$
17.92
$
17.92
Global
X-ray of mammary ducts-multiple (ducto/galactogram)
$
97.11
$
97.11
77054TC
TC
X-ray of mammary ducts-multiple (ducto/galactogram)
$
73.89
$
73.89
7705426
26
X-ray of mammary ducts-multiple (ducto/galactogram)
$
23.22
$
23.22
58110 +
76098
76645
76942
77031
77032
77053
77054
For persons with disabilities, this document is available on request in other formats. To submit a request, call 1-800-525-0127, (711).
$
62.92
Lab
Bundled
3
Bundled
Bundled
$
236.42
$
236.42
DOH 343-032 June 2012
BCCHP Allowable Reimbursement Schedule
Breast and Cervical Cancer Screening and Diagnosis
July 1, 2012 – June 30, 2013
CPT®
HCPCS
77055
Modifier
BREAST AND CERVICAL CANCER SCREENING AND DIAGNOSTIC PROCEDURES
Professional
Professional
Procedure Code Description
Hospital
Non-Facility
Facility
Outpatient
OFFICE
PROVIDER
Global
Mammogram, diagnostic follow-up, unilateral
$
97.18
$
97.18
77055TC
TC
Mammogram, diagnostic follow-up, unilateral
$
61.04
$
61.04
7705526
26
Mammogram, diagnostic follow-up, unilateral
$
36.13
$
36.13
Global
Mammogram, diagnostic follow-up, bilateral
$
124.44
$
124.44
77056TC
TC
Mammogram, diagnostic follow-up, bilateral
$
79.74
$
79.74
7705626
26
Mammogram, diagnostic follow-up, bilateral
$
44.70
$
44.70
Global
Mammogram, screening, bilateral (2 view film)
$
89.78
$
89.79
77057TC
TC
Mammogram, screening, bilateral (2 view film)
$
53.65
$
53.65
7705726
26
Mammogram, screening, bilateral (2 view film)
$
36.13
$
36.13
Global
Screening mammogram, digital, bilateral
$
156.76
$
156.76
G0202TC
TC
Screening mammogram, digital, bilateral
$
120.23
$
120.23
G020226
26
Screening mammogram, digital, bilateral
$
36.52
$
36.52
Global
Diagnostic mammogram, digital, bilateral
$
189.08
$
189.08
G0204TC
TC
Diagnostic mammogram, digital, bilateral
$
143.60
$
143.60
G020426
26
Diagnostic mammogram, digital, bilateral
$
44.48
$
44.48
Global
Diagnostic mammogram, digital, unilateral
$
149.36
$
149.36
G0206TC
TC
Diagnostic mammogram, digital, unilateral
$
112.83
$
112.83
G020626
26
Diagnostic mammogram, digital, unilateral
$
36.52
$
36.52
77056
77057
G0202
G0204
G0206
87621
Global
HPV, DNA, amplified probe(Digene® or Cervista®)
88108
Global
Cytopathology, concentration technique-smears and interpretation
$
79.03
$
79.03
88108TC
TC
Cytopathplogy, concentration technique-smears and interpretation
$
56.37
$
56.37
8810826
26
Cytopathology, concentration technique-smears and interpretation
$
22.66
$
22.66
Global
Cytopathology, selective cell enhancement technique/ interpretation
$
111.98
$
111.98
88112TC
TC
Cytopathology, selective cell enhancement technique/ interpretation
$
52.87
$
52.87
8811226
26
Cytopathology, selective cell enhancement technique / interpretation
$
59.11
$
59.11
88112
For persons with disabilities, this document is available on request in other formats. To submit a request, call 1-800-525-0127, (711).
$
61.04
$
79.74
$
53.65
$
120.23
Ambulatory
Surgery
Center
Lab
4
$
143.60
$
112.83
$
49.39
$
56.37
$
52.87
$
49.71
DOH 343-032 June 2012
BCCHP Allowable Reimbursement Schedule
Breast and Cervical Cancer Screening and Diagnosis
July 1, 2012 – June 30, 2013
CPT®
HCPCS
Modifier
88141
Global
88142
Global
88143
Global
88147
Global
88148
Global
88160
Global
BREAST AND CERVICAL CANCER SCREENING AND DIAGNOSTIC PROCEDURES
Professional
Professional
Procedure Code Description
Hospital
Non-Facility
Facility
Outpatient
OFFICE
PROVIDER
Cytopathology, cervical or vaginal-physician interpretation
Cytopathology, Liquid Based Pap, cervical or vaginal-collected in
preservative fluid, automated thin layer preparation, manual
screening under physician supervision
Cytopathology cervical or vaginal- collected in preservative fluid,
automated thin layer preparation, with manual screening and
rescreening under physician supervision
Cytopathology smears, cervical or vaginal-automated, physician
supervision
Cytopathology smears, cervical or vaginal-automated with manual
rescreening under physician supervision
Cytopathology smears, other source, screen and interpretation
$
$
31.52
$
Ambulatory
Surgery
Center
Lab
30.28
$
28.70
$
28.70
$
28.70
$
28.70
$
16.12
$
16.12
$
21.53
$
21.53
61.66
$
61.66
$
58.15
88160TC
TC
Cytopathology smears, other source, screen and interpretation
$
36.12
$
32.72
$
32.72
8816026
26
Cytopathology smears, other source, screening and interpretation
Cytopathology, Conventional Pap, slides, cervical or vaginal
(Bethesda System) manual screening under physician supervisionCytopathology, slides, cervical or vaginal (Bethesda System) manual
screening under physician supervision
Cytopathology, slides, cervical or vaginal (Bethesda System) manual
screening and rescreening under physician supervision
Cytopathology, slides, cervical or vaginal (Bethesda System) with
manual and computer-assisted rescreening under physician
supervision
Cytopathology, evaluation of Fine Needle Aspiration
$
25.53
$
25.43
$
25.43
$
14.97
$
14.97
$
14.97
$
14.97
$
14.97
$
14.97
$
14.97
$
14.97
$
57.38
$
57.38
$
17.08
$
36.81
88164
Global
88165
Global
88166
Global
88167
Global
88172
Global
88172TC
TC
Cytopathology, evaluation of Fine Needle Aspiration
$
21.72
$
21.72
8817226
26
Cytopathology, evaluation of Fine Needle Aspiration
$
35.67
$
35.67
Global
Cytopathology, evaluation of FNA-interpretation and report
$
152.79
$
152.79
88173TC
TC
Cytopathology, evaluation of FNA-interpretation and report
$
81.29
$
81.29
8817326
26
Cytopathology, evaluation of FNA-interpretation and report
$
71.50
$
71.50
88173
For persons with disabilities, this document is available on request in other formats. To submit a request, call 1-800-525-0127, (711).
DOH 343-032 June 2012
5
BCCHP Allowable Reimbursement Schedule
Breast and Cervical Cancer Screening and Diagnosis
July 1, 2012 – June 30, 2013
CPT®
HCPCS
Modifier
88174
Global
88175
Global
88305
Global
BREAST AND CERVICAL CANCER SCREENING AND DIAGNOSTIC PROCEDURES
Professional
Professional
Procedure Code Description
Hospital
Non-Facility
Facility
Outpatient
OFFICE
PROVIDER
Cytopathology, cervical or vaginal, collected in preservative fluid,
automated thin layer, screening automated system, MD supervision
Cytopathology, cervical or vaginal, collected in preservative fluid,
automated thin layer, automated screening, manual rescreening, MD
supervision
Tissue pathology-gross and microscopic (IV)
$
117.88
$
117.88
88305TC
TC
Tissue pathology-gross and microscopic (IV)
$
79.74
$
79.74
8830526
26
Tissue pathology-gross and microscopic (IV)
$
38.15
$
38.15
Global
Tissue pathology-gross and microscopic (V)
$
261.40
$
261.40
88307TC
TC
Tissue pathology-gross and microscopic (V)
$
117.86
$
117.86
8830726
26
Tissue pathology-gross and microscopic (V)
83.54
100.92
$
$
83.54
100.92
88307
Global
Pathology consultation, first tissue block/frozen single specimen
$
$
88331TC
TC
Pathology consultation, first tissue block/frozen single specimen
$
38.46
$
38.46
8833126
26
Pathology consultation, first tissue block/frozen single specimen
$
62.45
$
62.45
Global
Pathology consultation, additional tissue block/frozen section(s)
$
44.16
$
44.16
88332TC
TC
Pathology consultation, additional tissue block/frozen section(s)
$
13.15
$
13.15
8833226
26
Pathology consultation, additional tissue block/frozen section(s)
$
31.01
$
31.04
Global
Immunohistochemistry each antibody
$
116.91
$
116.91
88342TC
TC
Immunohistochemistry each antibody
$
73.89
$
73.89
8834226
26
Immunohistochemistry each antibody
$
43.02
$
43.02
88331
88332
88342
CPT®
HCPCS
Evgcm
Modifier
Global
MISCELLANEOUS PROCEDURES
Professional
Procedure Code Description
Non-Facility
OFFICE
For persons with disabilities, this document is available on request in other formats. To submit a request, call 1-800-525-0127, (711).
Lab
$
30.26
$
30.26
$
37.52
$
37.52
$
36.81
$
57.66
$
36.81
6
$
11.16
$
36.81
Professional
Facility
PROVIDER
Vaginal estrogen cream (pay actual amount) maximum $150.00
Ambulatory
Surgery
Center
Hospital
Outpatient
$
Ambulatory
Surgery
Center
Lab
150.00
DOH 343-032 June 2012
BCCHP Allowable Reimbursement Schedule
Breast and Cervical Cancer Screening and Diagnosis
July 1, 2012 – June 30, 2013
END NOTES
Use the Healthcare Common Procedure Codes (HCPCS) or Current Procedural Terminology® (CPT®) codes and modifiers. Providers must bill using these descriptions. Reimbursement for all
procedures follows Medicare rules. Procedures cannot be reimbursed for more than Medicare allows. Washington state BCCHP uses Locality Code 2 calculations based on King County rates.
The type and duration of office visits should be appropriate to the level of care needed. Reimbursement rates will not exceed those published by Medicare. Codes 99385, 99386, 99387 will be
reimbursed at the 99203 code rate following CDCs program requirements. Codes 99396 and 99397 will be reimbursed at the 99213 code rate following CDCs program requirements.
Consultations should be billed through Evaluation and Management (E/M) codes. Consultations must meet the criteria for the code. Type and duration of E/M visits should be appropriate to the
level of care needed for performing screening and diagnostic follow-up.
Anesthesia services are reimbursed using Medicare's methodology. [(Base Unit + Time Unit) x Conversion Factor = Fee]. The program does not reimburse for propofol. The program has
established a $250.00 maximum reimbursement fee. Payment above the maximum fee may be considered with sufficient justification.
Codes 88143, 88174 and 88175 will be reimbursed at the 88142 rate based on CDC requirements.
Treatment of pre-cancerous conditions, breast and cervical cancer is not reimbursable. The program will refer women to Medicaid treatment programs based on eligibility.
Some procedures are bundled - reimbursement is associated with another procedure. Procedures performed in a hospital outpatient or ambulatory surgery center settings are usually bundled..
Endoscopy procedures (colposcopy) are based on “family” codes. Provider fees will be paid following the Medicare endoscopy rules: when two endoscopies in the same family are performed,
the endoscopy with the highest fee schedule amount will be paid at 100%. Additional related endoscopies are priced by subtracting the base endoscopy price. The amount of the base
procedure code will be paid. Professional facility provider fees for additional codes in the family will be reimbursed as add-on procedures for additional codes. Payment for the base procedure
is included in the payment for the most expensive endoscopy. Facility fees will be paid as follows: The endoscopy with the highest fee schedule will be paid at 100%. Additional related
endoscopies will be paid at 50% the highest price endoscopy in the “family” code.
Reimbursement for pre-operative, intra-operative, post-operative, routine follow-up care is bundled into the procedure code. This also includes any complications resulting from the procedure.
E/M visits are not payable for pre-operative care or post-operative follow-up. An E/M visit may be separately payable if the service is for the underlying condition related to the screening results.
An appropriate diagnosis code must be documented. Code 36415 may only be billed once per encounter for the collection of single or multiple specimens by the facility performing the
procedure. Billing for specific laboratory or diagnostic tests should be done by the facility performing the laboratory test.
Endoscopy codes G0104, G0121 or G0105 should be used for screening. Code 45330 (and family codes) and Code 45378 (and family codes) should be used if screening turns into a
diagnostic procedure.
Cervical Cancer Screening will be reimbursed following the US Preventive Services Task Force USPSTF Screening Guidelines and program eligibility criteria. HPV DNA High Risk (HR)
testing is reimbursable when used in co-testing with Pap cytology following the USPSTF Guidelines. Guidelines are the same regardless of whether collection is liquid-based or conventional
(slide-based). HPV DNA HR is also reimbursement for follow-up of an abnormal Pap cytology or surveillance following the American Society for Colposcopy and Cervical Pathology (ASCCP)
or National Comprehensive Cancer (NCCN) guidelines. Testing low-risk HPV types is not reimbursable. Genotyping is not reimbursable.
Computer Aided Detection (CAD) in breast cancer screening or diagnostics is not reimbursable.
Magnetic Resonance Imaging (MRI) in breast cancer screening or diagnostics is not reimbursable.
Breast cancer screening will be reimbursed following the USPSTF guidelines and program eligibility criteria. Diagnostic services will be reimbursed following the NCCN Guidelines.
Genetic testing for breast cancer risk is not reimbursable by the program.
Screening or care for other conditions is not reimbursable by the program.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
References:




Current Procedural Terminology® (CPT®) 2011 – American Medical Association (AMA)
Healthcare Common Procedure Coding System (HCPCS) 2011, Centers for Medicare and Medicaid Services (CMS)
Noridian Administrative Services: https://www.noridianmedicare.com/p-medb/%3f
Centers for Medicare and Medicaid Services (CMS): http://www.cms.gov/
For persons with disabilities, this document is available on request in other formats. To submit a request, call 1-800-525-0127, (711).
DOH 343-032 June 2012
7