How does CMS define the "12 month" rule for screening mammogram eligibility?

September 20, 2009 by admin

Preventive (screening) mammograms are covered once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between age 35 and 39. Please Note: Medicare will deny (not pay) claims for screening mammograms performed too soon. To determine the 12-month period, start your count beginning with the month after the month in which a previous screening mammogram was performed. The following examples will help you understand the 12-month rule. EXAMPLE 1: Mrs. Smith received a screening mammogram on February 20, 2009. She would begin counting her 12 months with March 2009, the month after the month she had her previous screening mammogram. In this example, February 2010 would be the 12th month. She is eligible to receive another screening mammogram on February 1, 2010 or later (the month after 11 full months have elapsed or later). EXAMPLE 2: Mrs. Jones received a screening mammogram on August 1, 2008. She calls her doctor's office to schedule an appointment for another screening mammogram and is offered an appointment for July 26, 2009. Mrs. Jones tells her doctors office that this appointment is too early to be covered by Medicare - the appointment must be in August to be covered by Medicare. Otherwise she might have to pay for the entire cost of the screening mammogram if she goes ahead and has the exam in July. Additional questions regarding screening mammography coverage can be answered by calling 1-800-MEDICARE (1-800-633-4227).