Program Updates 

Providers: New Information | CME Opportunities | Forms & Manuals | Clinical Guidelines | Provider Enrollment

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.

Effective January 1, 2012, Arkansas BreastCare will convert to HIPAA X12 version 5010 for electronic transactions including eligibility (270/271), claims (837P) and claims status (276/277).

Effective December 5, 2009, BreastCare coverage for women will no longer be retroactive 30 days preceding the enrollment date. Thus, we ask providers to be sure you see the patient’s current enrollment card or that you call the enrollment center at 1-877-670-2273 to be sure the patient is enrolled before providing any service. Any service provided prior to the patient’s enrollment date will not be covered including, but not limited to, mammograms and office visits.

Surgical Follow-Up

BreastCare patients may receive follow-up after a mammographic abnormality or benign biopsy for one year. After one year patients go back into annual screening with their Primary Care Providers (PCP). The cycle starts over with another mammogram. Any time that the mammogram is abnormal the patient may receive a biopsy or be referred back to the surgeon if appropriate. An annual visit to the PCP is important. In addition to breast screening, patients receive a Pap test every two (2) years per BreastCare policy.

Category 0 – Need additional imaging evaluation and/or prior mammograms for comparison

BreastCare is now required by CDC to track mammograms with Category 0 that need additional imaging separately from mammograms with Category 0 that require prior films for comparison. BreastCare is responsible for reporting if the comparison with prior films was made and the final imaging outcome. Please help by clearly indicating on the mammogram report if prior films have been requested for comparison.

Physician Orders for Diagnostic Mammograms

BreastCare clients are required to have Physician Orders for diagnostic mammograms. When a client arrives at the mammography facility for her appointment without a Physician Order, the facility will call the provider to request an order. Please fax the order ASAP. The patient will be waiting and may not understand why she has to wait so long or even why her mammogram cannot be performed at all. Please remember to fax the order when a mammogram is scheduled. This will save time and prevent conflict between the provider and the patient.

Revised BreastCare Physician Order

Both ultrasound and diagnostic mammogram are required and should be ordered when a patient is referred for a palpable mass. The BreastCare Physician Order has been revised to include orders for breast ultrasound and diagnostic mammogram 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 sent back to the facility for the procedure. You may call (501) 661-2636 to obtain a copy of the BreastCare Physician Order.

Effective July 1, 2009, digital mammograms are reimbursed by BreastCare. Please indicate on the mammogram report what type of mammogram is performed.

Effective January 1, 2009, BreastCare will now cover CPT codes 19110 (nipple excision) and 76998 (ultrasound guided localization, intraoperative guidance).

Effective January 1, 2009, BreastCare will now cover CPT code 57420 (colposcopy for entire vagina and cervix, if present). A result and recommendation code is required and payment is limited to certain diagnosis. Please see billing manual for billing criteria.

Effective January 1, 2009, BreastCare will now cover CPT codes 19110 (nipple excision) and 76998 (ultrasound guided localization, intraoperative guidance).

Effective January 1, 2009, BreastCare will now cover CPT code 57420 (colposcopy for entire vagina and cervix, if present). A result and recommendation code is required and payment is limited to certain diagnosis. Please see billing manual for billing criteria.

How are we doing? BreastCare Establishes Quality Indicators BreastCare has established new quality of care indicators for breast and cervical cancer screening. The 41 new breast cancer indicators and 29 new cervical cancer indicators were established after members of a workgroup spent more than a year defining indicators and establishing goals for indicator achievement.

  • Breast Cancer Indicators
  • Cervical Cancer Indicators

Effective June 30, 2008, reimbursement rates for office visits have decreased per the CDC policy dated December 11, 2007. This is for plans B and C only. The procedure codes effected are 99204, 92205, 99214 and 99215.

Effective May 19, 2008, BreastCare will only accept the NPI on claims and eligibility requests. All claims will require an NPI including those submitted on the Internet, Provider Electronic Solutions software and paper. BreastCare Provider Numbers will no longer be accepted on claims. Billing providers, performing providers and referring providers will need to be identified on a claim using NPIs. Any claims received with a BreastCare Provider Number after this date will not be paid.

We encourage you to begin using your NPI immediately for billing. If you need assistance using your NPI for billing, please call the EDS BreastCare Call Center (1-877-670-2273 or local 501-372-0225).

If you need to link an NPI to your BreastCare Provider Number, we encourage you to use our Web-based application. Go to Medicaid and select the Provider section. Enter your BreastCare Provider Number and password to access the NPI reporting tool. You may also need your taxonomy code (if applicable) to link your NPI. If you need assistance linking your NPI or using the Web site, call the EDS BreastCare Call Center at 1-877-670-2273 or local 501-372-0225.

Effective April 14, 2008, laboratory providers (provider types 22 and 69) will be required to submit the referring provider information on all claims starting on this date. If the referring provider information is not completed, you will receive a rejection up front stating: 2330, a referring provider number missing or not on file. This will be used for quality assurance purposes. When Pap tests are done on women who have had hysterectomies for benign conditions, medical necessity will be investigated.

Effective January 1, 2008, BreastCare will now cover CPT Code 57510: cauterization of the cervix, for those patients requiring treatment and do not qualify for BreastCare medicaid.

Effective January 1, 2008, BreastCare will now cover CPT Code 57105: vaginal biopsy and Code 88321: slide consult for all plans. Reimbursement for 57105 is limited to certain diagnosis codes.

Provider Reporting Form for Primary Care Providers

A new form has been developed for primary care providers to report the CBE result, Pap information and mammogram appointments for BreastCare clients. This form must be completed and faxed to 501-661-2264 within five days after a BreastCare visit. BreastCare must have this information to budget appropriately, to refill slots for missed appointments and to be able to assist women when they call for help. Please begin using the enclosed form immediately (See Provider Reporting Form under “Forms”). This form replaces the BCCCP-2 form used by AHECs and CHCs. All primary care providers are to use this form now.

Mammography Facilities Will See Change – Ultrasound Required for Palpable Mass

Providers will be scheduling breast ultrasounds when a palpable mass is found on clinical breast exam. A diagnostic mammogram and breast ultrasound should be done on the same day for the patient’s convenience and to ensure adequate follow-up. Per BreastCare policy, if a simple cyst or benign abnormality is revealed on ultrasound, a surgical consult is not required.

Screening Mammogram Results

Probably Benign BIRADS 3 requires a full imaging work-up. This result should not be reported for a screening mammogram unless additional diagnostic procedures have been performed.

CBE Not Required within 60 days of Mammogram

Patients will receive an annual clinical breast exam, but an exam is no longer required to be within 60 days before the mammogram.
Scheduling Mammograms

Mammograms may be scheduled in the same month as performed in the previous year. It is no longer required to be 365 days from the date of the last mammogram.

Timeline for Receiving Pap Results

Results should be received within 21 calendar days from date of Pap. The cytology lab should report results to the Provider within 3 calendar days after receiving the Pap specimen. Utilization of a Pap Log is necessary to track receipt of Pap test results.

Referrals to Regional Care Coordinators

A Pap test result of Atypical Squamous Cells of Undetermined Significance (ASC-US) now requires that an HPV High Risk DNA test be performed. If the HPV test is positive, colposcopy is required. If the HPV test is negative, a follow-up Pap test is required within six to 12 months. All Pap or HPV tests requiring colposcopy should be referred to the Regional Care Coordinator to assure timely follow-up.

Liquid-Based Pap Test (LBT) versus Conventional Pap Smears

Liquid-based Pap tests are now available to BreastCare clients. LBT are reimbursable according to professional standards every two years. BreastCare clients should receive LBT which is the standard of care over conventional Pap tests. Conventional Pap smears should not be substituted just so a Pap can be performed every year. The patient will be seen by the primary care provider yearly for a CBE regardless of eligibility for Pap.

Surgical Consult Requirements

Mammography films must be taken to all surgical appointments. When surgical consultations are scheduled, patients should be instructed to take films to the appointment. The surgeon must be able to review the films to make an adequate evaluation.

Providers Change of Status

Providers sometimes move, retire or just choose to stop participating in BreastCare. Any changes in your address, phone number, bank account or tax ID should be reported in writing to Shiela Couch by faxing the information to 501-661-2009 or mailing it to 4815 W. Markham, Slot 11, Little Rock, AR 72205. Your provider file will be updated. Call 501-661-2836 with questions.

Endocervical Cells

Absence of endocervical cells is normal in a post-menopausal woman. A Pap test should not be repeated in this situation.

Quality Assurance Reviews for Community Health Centers

Quality Assurance Audits will be conducted on-site at Community Health Centers across the state beginning in Fiscal Year 09. An audit tool has been developed and will be used by the BreastCare Quality Assurance Specialist. More details will be provided as this process is developed.

BreastCare Patients Should Not Receive Bills for Mammograms!

All annual exams for CBE, Pap and mammograms must be scheduled by the BreastCare Phone Center. Primary Care Providers must make sure that a woman is currently enrolled in BreastCare before providing these services for a BreastCare client.

Mammography facilities must make sure she is currently enrolled before performing a mammogram. Check her BreastCare Identification Card to make sure that her eligibility date is current. If she cannot present her card, call 1-877-670-2273 to verify her eligibility. Reimbursement for the office visit and mammogram will be denied if the woman is not currently enrolled in the BreastCare program. Please help prevent this from happening.

Shortage of Primary Care Providers in Northwest Arkansas and Garland County

Based on the number of women needing BreastCare exams, the program needs more providers in certain counties in Northwest Arkansas and Garland County. Currently there are three providers in Springdale, one in Fayetteville and one in Bentonville. This makes it difficult to schedule patients for CBEs and Paps in a timely manner. It may be three to four weeks before a woman can receive an appointment. In addition, obtaining appointments for symptomatic women has become a problem. There is also a shortage of colposcopy providers in Southeast Arkansas.

If you know of any providers in these counties that would be willing to participate in the BreastCare program, please contact Becky Kossover, Contract and Accounts Manager, 501–280-4097.

Pap Requisition When the Pap Specimen is Mailed

The BreastCare ID number must be entered on the Cytology Requisition. The cytology lab cannot bill without the patient’s ID number. If a patient enrolls in BreastCare after she has seen the Provider and received a Pap test, the lab still must have the BreastCare ID number. The best thing to do is allow the patient to use a clinic phone to enroll before she leaves and obtain her BreastCare ID number so it can be entered on the Cytology Requisition and mailed with the Pap specimen.

What Providers Should Know …. About Breast and Cervical Cancer Medicaid

Breast and Cervical Cancer patients and patients with precancerous cervical conditions (CIN II, III, CIS) are enrolled in Breast and Cervical Cancer Medicaid (Plan description “07”) for treatment. BreastCare is not their insurance for treatment, but is being overwhelmed with questions about Medicaid. At the time of enrollment in Medicaid, patients receive extensive counseling regarding Medicaid coverage, a detailed Medicaid brochure, a fact sheet about Medicaid coverage with resource information and contact phone numbers. Please refer these patients to those documents given to them or to Medicaid client assistance at 1-800-482-5431. The following issues cause patients to receive bills:

  • The cancer diagnosis was not entered as the primary diagnosis on the claim. Medicaid category 07 will not pay for diagnosis of “history of malignancy”.
  • The patient has not understood she must have a Medicaid PCP. She considers either her family physician or the specialist she has seen as her PCP. These physicians are not always Medicaid PCPs.
  • The patient has no benefit limit (with the exception of consults) when the services pertain to treatment for cancer and a cancer diagnosis code is entered on claim.