Is a physician’s prescription required for Medicare to cover a screening mammography?
No, a doctor’s prescription or referral is not necessary for the procedure to be covered. Whether payment can be made is determined by a woman’s age and statutory frequency parameter. Section 4101 of the Balanced Budget Act (BBA) of 1997 provides for annual screening mammographies for women over age 39 and waives the Part B deductible. Coverage applies as follows:
- Under age 35—no payment allowed
- From 35–39—baseline (payment for only one screening mammography performed on a woman between her 35th and 40th birthday
- Over age 39—annual (11 full months have elapsed following the month of last screening).
More information about screening mammography can be found in the Medicare Claims Processing Manual, Chapter 18, Section 20 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf.
This question was answered in an edition of our Radiology Compliance Manager. For more hot topics relating to radiology services, please view our store, or call us at 1.800.252.1578 ext. 2.