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New Information
CPT Codes
Effective March 5, 2012, BreastCare will cover CPT Codes:
- CPT 38500 (biospy or excision of lymph node(s), open, superficial) reimbursed at:
- $292.95 for the professional component and
- $919.40 for outpatient surgery.
- CPT 38525 (biopsy or Excision of lymph node(s), open, deep axillary nodes) reimbursed at:
- $386.06 for the professional component and
- $919.40 for outpatient surgery
- Codes are limited to 2 per DOS, 4 per year.
- CPT 01610 (anesthesia for excision of lymph nodes(s)) reimbursed at:
- $441.61 for the professional component, limited to 2 per year. Payment is limited to certain diagnosis codes.
BreastCare Order for Mammograms and Ultrasounds
Effective August 2011, mammogram facilities will be receiving an order for mammograms and ultrasounds signed by the ordering clinician, an APN or physician, with their NPI number listed. Medicare payment policy no longer permits the use of rubber stamps. Therefore; Arkansas BreastCare is discontinuing the use of rubber signature stamps.
Patient Search Problem Has Been Fixed.
Please be aware of new information recently provided to BreastCare providers regarding testing, covered procedures and codes.
Online BreastCare Enrollment and Reporting
A new online data entry system will go live July 1, 2011, for Community Health Centers, AHECS, and Primary Care Providers. Client enrollment will be decentralized to increase access to enrollment by allowing women to assess eligibility or by contacting a local participating BreastCare Primary Care Provider (PCP). Eligible women will make an appointment with a local provider for a clinical breast exam and Pap test if needed. When the patient is seen, the PCP will enroll her and enter her screening information and mammogram appointment electronically into the BreastCare database via the internet. All test results and recommendations must be entered electronically before claims are submitted. All claims for office visits will be rejected if CBE, Pap test and mammogram results are not in the system when the claim is received. Confidential reports will be made available to each participating provider to help improve their tracking system. The new system will increase the program’s ability to screen more women and provide additional clinical services while improving client and provider satisfaction.
Provider Contract Online
The Public Health Service Agreement for FY 11 will be completed electronically via the internet at https://health.arkansas.gov/breastcareonline. The agreement must be printed, signed, and mailed to Arkansas Department of Health, Shiela Couch, 4815 W. Markham, Slot 11, Little Rock, AR 72205. New agreements or renewal must be completed and submitted to the Arkansas Department of Health by July 1, 2011 for BreastCare services to be reimbursable.
Treatment Benefit Limits
Effective July 1, 2011, the procedure for referring patients diagnosed with breast or cervical cancer, CIN II, or CIN III for treatment is changing. The physician’s office must call the BreastCare program at 501-661-2513 to refer the patients and verify their diagnosis. The patient will then be contacted by the BreastCare Case Manager to complete the Medicaid application. Women cannot be enrolled for Medicaid until the physician has called.
Treatment covered by BreastCare is limited to patients who are eligible for Breast and Cervical Cancer Medicaid category 07. State funds do not cover treatment services for breast or cervical cancer or precancerous cervical conditions. All claims for a BreastCare enrollee diagnosed with breast or cervical cancer and who is also a Medicaid recipient are billed to Medicaid and covered according to Medicaid’s guidelines. BreastCare does not pay claims for treatment.
Eligibility Criteria Changed
Women with comprehensive health insurance which covers inpatient, outpatient, and physician services can no longer receive BreastCare services even if they have a high deductible and/or co-payment.. Plan A and Plan C remain for women who are uninsured or have non-comprehensive insurance such as a cancer policy or hospitalization only policy.
Ultrasound Required for Palpable mass
Breast ultrasound and diagnostic mammogram must be ordered per BreastCare policy in the presence of a palpable mass. These procedures should be done on the same day for the convenience of the patients and to decrease delay in diagnosis. If the ultrasound is not performed when ordered, the patient will be rescheduled at the same facility for the procedure. The patient must be referred for a surgical consultation unless the ultrasound reveals a cyst or benign abnormality.
Referrals to Arkansas Tobacco Quitline
The smoking status of all BreastCare clients must be reported to BreastCare on the Screening Form. Current smokers should be referred to 1-800-Quit-NOW (1-800-784-8669 for assistance to quit smoking.