Provider Information

The Wyoming Cancer Program (WCP) provides limited coverage for screening and early detection of breast or cervical cancer.  If a breast or cervical cancer screening test is abnormal or suspicious, the program may cover appropriate diagnostic procedures until a final diagnosis is reached.  

Prior to performing services for an enrolled patient, please refer to the current list of reimbursable CPT codes, allowable modifiers, and pre-authorization codes. The program must approve all pre-authorization codes before the services are performed. 

Reimbursement is contingent upon the submission of clinical documentation. 

Breast and Cervical Cancer Screening Program covered services:

The program recommends that providers refer to the current allowable CPT code list. Expenses are reimbursed by the program at the Medicare allowable rate, and include, but are not limited to:

• 2D Mammograms
• 3D Mammograms***
• Breast MRI***
• Diagnostic mammograms
• Breast ultrasounds
• Breast biopsies
• Breast ductogram
• Breast galactogram
• Anesthesia for procedures related to breast or cervical cancer screenings and diagnostic testing
• Placement of breast localization device
• Breast tomosynthesis (77063)
• Clinical breast exams
• Pap tests
• HPV tests***
• Colposcopies
• Office visits where breast or cervical cancer screenings are discussed and recommended. Please note that the WCP does not cover more than one office visit per year. 
• Repeat Pap tests, mammograms, breast ultrasounds, and CBE that are approved for short-term follow-up at intervals less than one year
• Repeat Pap tests when specimen adequacy is deemed “unsatisfactory”
• Short-term follow-up Pap tests after previous abnormal test results
• HPV testing for clients 30 years and older every 5 years with hrHPV and cytology (co-testing) or every 5 years with hrHPV testing alone

***Please see the additional information section listed below for details on coverage and limitations for these services. 

Services that require Pre-authorization:

• Excision of Breast Cyst. Excisional lumpectomy is allowable when a breast biopsy is inconclusive, and a lumpectomy is needed to determine a diagnosis. 
• Excision of Breast Lesion: Identified by pre-operative placement of radiological marker, single lesion, and/or each additional lesion. Excisional lumpectomy is allowable when a breast biopsy is inconclusive, and a lumpectomy is needed to determine a diagnosis. 
• Conization of the Cervix – Facility Setting: with or without fulguration, with or without dilation and curettage: Reimbursement allowed only when a Colposcopy biopsy is inconclusive and a diagnosis is needed. (not allowable for treatment)
• Loop electrode excision – Facility Setting: Reimbursement allowed only when Colposcopy biopsy is inconclusive and a diagnosis is needed. (not allowable for treatment)
• Endometrial sampling – Facility Setting: (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure). Reimbursement allowed only after an AGUS Pap result.
• Endometrial sampling – Facility Setting: (biopsy) performed in conjunction with colposcopy (list separately in addition to code for primary procedure). Reimbursement allowed only after an AGUS Pap result.

It is essential that services requiring pre-authorization receive program approval. Any services provided without this approval, especially those unrelated to diagnostic screenings or that fall outside program coverage guidelines, will be denied payment or, if paid, subject to recovery if determined to be ineligible.

Non-covered services:

• Telephone consultations 
• Removal of polyps
• Blood work
• Pregnancy Tests
• STI testing
• Urine analysis
• BRCA gene testing
• Chest X-rays
• EKGs
• Pelvic ultrasounds
• Bone scans
• Uterine biopsies
• D & C
• Nuclear studies
• Prescriptions
• CT scans
• Breast tomosynthesis (77061 unilateral or 77062 bilateral)
• Second office visits, which are made to complete a pelvic examination, Pap test, or CBE (all of these procedures should be completed in one office visit)
• Inpatient hospital services
• Evaluations of vaginal or vulvar lesions
• Repeat Pap tests performed simultaneously with colposcopy or colposcopy with biopsy (unless more than four months have passed since the initial Pap test was performed)
• Anything related to other cancers (including the uterus, vagina, vulva, ovaries, etc.)
• Any services that are not related to breast or cervical cancer screening
• Treatment for breast, cervical, and pre-cervical cancer 
• Missed appointments

The program can only pay for a vaginal smear if the client previously had a hysterectomy due to cervical cancer. 

If providing services to a program client that are outlined in the non-covered services section, it is encouraged that the provider discuss the costs of these services with the client prior to completing the service. 

Additional Information

3-D Mammography

The program will reimburse for film, digital, and 3-D mammography up to the Medicare reimbursement rate. All women should be counseled on the benefits and risks of mammography. If a woman has the option of having a 3-D mammography, she should be counseled on the benefits and risks of 3-D mammograms versus 2-D mammograms to make an informed decision. 

Magnetic Resonance Imaging (MRI) 

The program will reimburse for screening breast MRI performed in conjunction with a mammogram when a client has been determined to be high risk (e.g., has a BRCA mutation, a first-degree relative who is a BRCA carrier, or a lifetime risk of 20-25% or greater as defined by risk assessment models). Breast MRI can also be reimbursed when used to better assess areas of concern on a mammogram or for the evaluation of a client with a past history of breast cancer after completing treatment. Breast MRI should never be done alone as a breast cancer screening tool. 

Breast MRI is not reimbursable when used to assess the extent of disease staging in women who were recently diagnosed with breast cancer and are preparing for treatment. 

Reimbursement of HPV DNA Testing 

HPV DNA testing is reimbursable when used for screening or follow-up of abnormal Pap results. HPV genotyping is reimbursable when used for follow-up of abnormal cervical cancer screening results as per ASCCP algorithms. Providers should specify the high-risk HPV DNA panel only. Low-risk HPV DNA panels are not reimbursable.  

Required Documentation: 

As outlined in the Wyoming Medicaid Provider Agreement, the Wyoming Cancer Program requires supporting documentation for the reimbursement of claims. Provider reimbursement is contingent on timely and accurate submission of the applicable documentation. 

Providers may submit supporting documentation electronically with claim submission, via fax, or email. If the supporting documentation is not received within 30 days of the electronic claim submission, the claim may be denied and payment may be reversed. 

Applicable documentation for breast and cervical cancer screenings would include pathology reports, radiology reports, and office visit notes. 

WBCCSP CPT Code List

Diagnosis codes

Client Enrollment Process and Forms

Notice of Privacy Practices

Aviso de Prácticas de Privacidad

The Wyoming Cancer Program (WCP) provides limited coverage for screening and early detection of colorectal cancer.  If a colorectal cancer screening test is abnormal or suspicious, the program may cover appropriate diagnostic procedures until a final diagnosis is reached.  

Reimbursement is contingent upon the submission of clinical documentation. 

Colorectal Cancer Screening Program covered services:

The program recommends that providers refer to the current allowable CPT code list found below. Expenses are reimbursed by the program at the Wyoming Medicaid allowable rate, and include, but are not limited to:

• Office visit during which colorectal cancer screening is discussed and recommended. Please note that the WCP does not cover more than one office visit per year. 
• Pre-operative consultation fees
• Colonoscopy procedures
• Level IV surgical pathology, and gross and microscopic examinations (for colon only)
• Facility fees for colorectal cancer screening-related services
• Sedation or anesthesia fees for colonoscopy only
• Labs: Comprehensive Metabolic Panel, Hematocrit and Hemoglobin, Complete Blood Smear, Prothrombin time, Thromboplastin time
• Electrocardiogram
• Sigmoidoscopy (only if colonoscopy is incomplete)
• CT colonography (only if colonoscopy is incomplete)
• Contrast Barium Enema (only if colonoscopy is incomplete)
• Other at-home stool testing options may be available for asymptomatic and average-risk patients. Contact the program to discuss options.
  • Lab processing for stool-based testing

Non-covered services:

Services not covered by the WCP include, but are not limited to:

• Genetic testing
• Esophagogastroduodenoscopies (EGD)
• Pathology and/or biopsies unrelated to colorectal cancer screening
• Digital rectal exam if not part of FOBT
• Post-op office visits
• Removal of hemorrhoids, hemorrhoidectomies, hemorrhoid banding, or hemorrhoid lancing
• Treatment for colon cancer, inflammatory bowel disease, or any other condition requiring treatment
• Adverse side effects

When providing non-covered services to a program client, it is encouraged that the provider discuss the costs of these services with the client prior to completing the service. If providers have any questions about the services listed above, they may contact the program.

Required Documentation

As outlined in the Wyoming Medicaid Provider Agreement, the Wyoming Cancer Program requires supporting documentation for the reimbursement of claims. Provider reimbursement is contingent on timely and accurate submission of the applicable documentation. 

Providers may submit supporting documentation electronically with claim submission, via fax, or email. If the supporting documentation is not received within 30 days of the electronic claim submission, the claim may be denied and payment may be reversed. 

Applicable documentation for colorectal cancer screenings would include surgical reports, pathology reports, and office visit notes. 

WCCSP CPT Code List

Diagnosis codes

Client Enrollment Process and Forms

Notice of Privacy Practices

Aviso de Prácticas de Privacidad