GE Healthcare

somov Automated Breast Ultrasound System (ABUS) for Breast Cancer Screening

May, 2013
www.gehealthcare.com/reimbursement

In 2012, the somo v* Automated Breast Ultrasound System (ABUS*) was approved by the FDA1 as an adjunct to mammography for breast cancer screening in asymptomatic women for whom screening mammography ndings are normal or benign (BI-RADS** Assessment Category 1 or 2), with dense breast parenchyma (BI-RADS Composition/Density 3 or 4), and have not had previous clinical breast intervention.

Coding and Payment Information

It is the physicians ultimate responsibility to select the appropriate CPT** code(s)2 for the procedure(s), and to report the International Classication of Diseases, Ninth Revision, Clinical Modication (ICD-9-CM) diagnosis code based on his or her ndings or the pre-service signs, symptoms or conditions that reect the reason for using the somo v ABUS.3 Examples of possible ICD-9-CM codes that may be used to report a screening condition are listed to the right. ICD-9-CM Code Description 793.82 Inconclusive mammogram Dense breasts NOS Inconclusive mammogram NEC Inconclusive mammography due to dense breasts Inconclusive mammography NEC V76.10 V76.19 Breast screening, unspecied Other screening breast examination

HCPCS Code/Description

Medicare Hospital Outpatient Payment4 $ 64.64

Medicare Freestanding Facility/Physician Ofce Payment5 Technical Professional Global $ 73.83 $ 26.54 $ 100.37 $ 44.57

Private Insurance Plans or Medicaid Payment Payment rates vary by insurer and contractual agreements Payment rates vary by insurer and contractual agreements

CPT 766456 Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation

APC 0265 CPT 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation
[Use 76377 in conjunction with code(s) for base imaging procedure(s)] [Do not report 76377 in conjunction with 70496, 70498, 70544-70549, 71275, 71555, 72159, 72191, 72198, 73206, 73225, 73706, 73725, 74174, 74175, 74185, 74261-74263, 75557, 75559, 75561,75563,75565,7557175574, 75635,76376, 78012-78999, 0159T]

Payment for this code is packaged into another procedure

Technical

Professional

$ 38.11

Global

$ 82.68

Coverage information
Procedures may be a covered benet if such usage meets all requirements established by the particular payer. However, for coverage of other indications, it is advisable that you verify coverage policies with your local Medicare Administrative Contractor. Also, it is essential that each claim be coded appropriately and supported with adequate documentation in the medical record. Coverage by private payers varies by payer and by plan with respect to which medical specialties may perform ultrasound services. Some private payer plans will reimburse for ultrasound procedures performed by any physician specialist while other plans will limit ultrasound procedures to specic types of medical specialties. In addition, plans may require providers to submit applications requesting these diagnostic ultrasound and ultrasound-guided services be added to the list of services performed in their practice. It is important that you contact the payer prior to submitting claims to determine their requirements.

Disclaimer
THE INFORMATION PROVIDED WITH THIS NOTICE IS GENERAL REIMBURSEMENT INFORMATION ONLY; IT IS NOT LEGAL ADVICE, NOR IS IT ADVICE ABOUT HOW TO CODE, COMPLETE OR SUBMIT ANY PARTICULAR CLAIM FOR PAYMENT. IT IS ALWAYS THE PROVIDERS RESPONSIBILITY TO DETERMINE AND SUBMIT APPROPRIATE CODES, CHARGES, MODIFIERS AND BILLS FOR THE SERVICES THAT WERE RENDERED. THIS INFORMATION IS PROVIDED AS OF JANUARY 1, 2013, AND ALL CODING AND REIMBURSEMENT INFORMATION IS SUBJECT TO CHANGE WITHOUT NOTICE. PAYERS OR THEIR LOCAL BRANCHES MAY HAVE DISTINCT CODING AND REIMBURSEMENT REQUIREMENTS AND POLICIES. BEFORE FILING ANY CLAIMS, PROVIDERS SHOULD VERIFY CURRENT REQUIREMENTS AND POLICIES WITH THE LOCAL PAYER. THIRD PARTY REIMBURSEMENT AMOUNTS AND COVERAGE POLICIES FOR SPECIFIC PROCEDURES WILL VARY INCLUDING BY PAYER, TIME PERIOD AND LOCALITY, AS WELL AS BY TYPE OF PROVIDER ENTITY. THIS DOCUMENT IS NOT INTENDED TO INTERFERE WITH A HEALTH CARE PROFESSIONALS INDEPENDENT CLINICAL DECISION MAKING. OTHER IMPORTANT CONSIDERATIONS SHOULD BE TAKEN INTO ACCOUNT WHEN MAKING DECISIONS, INCLUDING CLINICAL VALUE. THE HEALTH CARE PROVIDER HAS THE RESPONSIBILITY, WHEN BILLING TO GOVERNMENT AND OTHER PAYERS (INCLUDING PATIENTS), TO SUBMIT CLAIMS OR INVOICES FOR PAYMENT ONLY FOR PROCEDURES WHICH ARE APPROPRIATE AND MEDICALLY NECESSARY. YOU SHOULD CONSULT WITH YOUR REIMBURSEMENT MANAGER OR HEALTHCARE CONSULTANT, AS WELL AS EXPERIENCED LEGAL COUNSEL.

Please see inside pocket for Full Product Information.

1 Department of Health and Human Services Food and Drug Administration. September 18, 2012. Available at the following website, last accessed February 20, 2013. http://www.accessdata.fda.gov/cdrh_docs/pdf11/ p110006a.pdf. 2 CPT codes and descriptions only are copyright 2012 American Medical Association. All rights reserved. No fee schedules are included in CPT. The American Medical Association assumes no liability for data contained or not contained herein. 3 Reimbursement information is current as of February 26, 2013. 4 Third party reimbursement amounts and coverage policies for specic procedures will vary by payer and by locality. The technical component is a payment amount assigned to an Ambulatory Payment Classication under the hospital outpatient prospective payment system. These national amounts are published in the Medicare Hospital Outpatient Prospective Payment System Final Rule for CY2013 [Federal Register, Vol. 77(221), November 15, 2012.]

5 Third party reimbursement amounts and coverage policies for specic procedures will vary by payer and by locality. The technical and professional components are paid under the Medicare physician fee schedule (MPFS). These national amounts are based on the Medicare Physician Fee Schedule CY2013 Final Rule Payment Rates for CY2013 [Federal Register, Vol. 77(222), November 16 2012]. The conversion factor was established under section 601(a) of the American Taxpayer Relief Act of 2012. 6 Effective January 1, 2007, the Decit Reduction Act (DRA) capped payment for the technical component of imaging services at the rate applicable under the hospital outpatient prospective payment system (OPPS).

www.gehealthcare.com/reimbursement

2013 General Electric Company All rights reserved. General Electric Company reserves the right to make changes in specifications and features shown herein, or discontinue the product described at any time without notice or obligation. Contact your GE Representative for the most current information. GE and GE Monogram are trademarks of the General Electric Company. GE Medical Systems Ultrasound & Primary Care Diagnostics, LLC, a General Electric company, doing business as GE Healthcare. * Trademark of General Electric Company. ** Third party trademarks are the property of their respective owners. GE Healthcare 9900 Innovation Drive Wauwatosa, WI 53226 U.S.A. (888) 202-5528 www.gehealthcare.com

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