The American College of Radiology (ACR) is pushing for the Centers for Medicare and Medicaid Services (CMS) and private insurers to cover breast tomosynthesis.
Even though tomosynthesis is proven to have benefits over digital mammography, more research is needed to assess long-term clinical outcomes. Research investigating what subgroups of women based on age, breast density and frequency of exam would benefit the most from the exams, is also needed.
In order for that research to be carried out, the technology has to be widely available and reimbursement plays a major role in that.
CMS stated last November that tomosynthesis is an essential component of digital mammography and because of that it cannot be billed separately. But ACR responded to that by creating CPT codes for tomosynthesis when scientific literature showed that the technology met the American Medical Association (AMA) CPT Editorial Panel criterion.
In order to create a CPT Category 1 code, the association requires that a procedure is FDA approved and in general use. The codes were approved by the editorial panel in February.
ACR also worked with the AMA Relative Value Scale Update Committee to create Relative Value Unit (RVU) values for tomosynthesis. The values have been sent to CMS so that they can be assigned to the codes but they have to be kept confidential until they are finalized.
However, having a CPT code and RVU values does not mean that tomosynthesis will be covered. CMS is going to announce its decision at the end of October about what RVU values will be assigned to tomosynthesis and if they will pay for it separately.
