Significant Changes to Reimbursement Rates in Breast Cancer for 2014

Although the changeover to using ICD-10 billing codes won’t be mandatory until October 1, 2014, there are many coding changes to consider starting on January 1. Specifically, the reimbursement rate for some genetic testing and imaging involving breast cancer will see significant changes.

For example, reimbursement rates for the genetic tests that involve BRCA1 and BRCA2 will pay a maximum of $1440. That is a 48.5% decline from the rate of $2795 CMS paid in 2013, according to a post on the Centers for Medicare & Medicaid Services (CMS) website. And while Medicare patients make up a small proportion of patients who seek breast cancer genetic testing, private insurers often use CMS rates as the baseline to determine their reimbursement rates.

Approximately 7% of breast cancer and 11—15% of ovarian cancer cases are caused by mutations in the BRCA1 or BRCA2 genes. BRCA testing is recommended for women with a family history of breast, ovarian, and other cancers to identify if they have an increased genetic risk for developing the cancers. Some women who test positive for one or both mutations choose to have a preventive double mastectomy to reduce their risk of developing breast cancer.

CMS did allow for the possibility that it would revise the rate again later in the year. CMS said it would collect comments on the new rate from the public and Medicare contractors until January 27. If the agency decides to make revisions to the new rate, the changes will go into effect on April 1, 2014, according to the notice.

In addition to genetic testing reimbursement cuts, CMS will also pay less for codes involving breast biopsy and various computed tomography and magnetic resonance imaging (MRI) studies. Overall, reimbursement for breast imaging codes received the most substantial cuts in the final rule.

The changes apply to payments for bundle breast biopsy with imaging guidance for stereotactic, ultrasound, or MRI studies. CMS created six new codes for these procedures: 19081—19086. The agency also created eight additional new codes: 19281–19288 that bundle marker placement with imaging guidance for stereotactic, ultrasound, mammographic, or MRI studies. CMS did not cut reimbursement for all the codes. This last set will bring a 17% payment increase for 2014.