Home » Coverage for Screening Mammography CPT codes 77057, G0202, +77052

Coverage for Screening Mammography CPT codes 77057, G0202, +77052

Section 4163 of the Omnibus Budget Reconciliation Act of 1990 added §1834(c) of the Act to provide for Part B coverage of mammography screening performed on or after January 1, 1991. The term “screening mammography” means a radiologic procedure provided to an asymptomatic woman for the purpose of early detection of breast cancer and includes a physician’s interpretation of the results of the procedure. Unlike diagnostic mammographies, there do not need to be signs, symptoms, or history of breast disease in order for the exam to be covered.

A doctor’s prescription or referral is not necessary for the procedure to be covered. Payment may be made for a screening mammography furnished to a woman at her direct request, and based on a woman’s age and statutory frequency parameter.

Section 4101 of the Balanced Budget Act (BBA) of 1997 provides for annual screening mammographies for women over 39 and waives the Part B deductible, however, coinsurance is applicable.

Coverage applies as follows:

Less than 35 years old: No payment may be made for a screening mammography performed on a woman under 35 years of age.

35-39 years old: (Baseline). Pay for only one screening mammography performed on a woman between her 35th and 40th birthday.

Over age 39: For a woman over 39, pay for a screening mammography performed after 11 full months have passed following the month in which the last screening mammography was performed. To determine the 11-month period, intermediaries and carriers start counting beginning with the month after the month in which a previous screening mammography was performed.

For example: If Mrs. Smith received a screening mammography examination in January 2012, begin counting the next month (February 2012) until 11 months have elapsed. Payment can be made for another screening mammography in January 2013.

HCPCS codes:

77057    Screening mammography, bilateral (2-view film study of each breast)

G0202    Screening mammography, producing direct digital image, bilateral, all views

If Computer aided Detection is performed then CPT code 77052 (Add-on code) must be billed in conjunction with 77057 or G0202.

ICD-9 Codes that Support Medical Necessity

V76.11    Screening mammogram for high-risk patient

V76.12    Other screening mammogram

Applicable Modifiers

Modifiers GG and GH

For screening mammography that turns into diagnostic mammography report codes 77055 or 77056 with GH modifier. GH modifier denotes that diagnostic mammography converted from screening mammogram on the same day. When a screening and diagnostic mammogram is performed on the same patient on the same day, modifier-GG should be appended to the appropriate CPT/HCPCS code.

Modifier 52 for Unilateral Screening Mammogram

For those rare occasions when performing a unilateral screening mammogram, since 77057 is inherently bilateral, bill 77057 (and 77051, if appropriate) or G0202 with a modifier 52, reduced service, along with an explanation in Item 19 on the CMS 1500 claim form or the electronic equivalent.

The appropriate reduced charge for a unilateral mammogram should also be reflected on the claim based on the provider’s usual charge for a bilateral mammogram. Medicare will reimburse the lower of the actual billed amount or the fee schedule amount.

See also: Aetna Coverage for Mammogram & Cigna Coverage for Mammogram

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