How To Bill Screening & Diagnostic Mammography | Codes & Guidelines (2023)

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.

Mammogram CPT Codes

Underneath the descriptions of the CPT codes for screening & Diagnostic Mammogram.

Screening Mammogram CPT Code 77067

CPT 77067 Description: Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed.

Diagnostic Mammogram CPT Code 77065 & CPT 77066

CPT 77065 Description: Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral.

CPT 77066 Description: Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral.

Mammogram ICD 10 CM Codes

ICD 10 CM Z85.3: Personal history of malignant neoplasm of breast.

ICD 10 CM Z80.3: Family history of malignant neoplasm of breast.

ICD 10 CM Z12.31: Encounter for screening mammogram for malignant neoplasm of breast.

Reimbursement

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.

Modifiers For Screening & Diagnostic Mammography

For screening mammography that turns into diagnostic mammography report codes CPT 77055 or CPT 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.

For those rare occasions when performing a unilateral screening mammogram, since CPT Code 77057 is inherently bilateral, bill CPT Code 77057 (and CPT 77051, if appropriate) 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