HCPCS Code G0202 – Screening mammography, producing direct digital image, bilateral, all views.

HCPCS Code G0204 – Diagnostic mammography, producing direct digital image, bilateral, all views.

HCPCS Code G0206 – Diagnostic mammography, producing direct digital image, unilateral, all views.

CPT Code 76085 – Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, screening mammography. (List separately in addition to code for primary procedure)

HCPCS Code G0236 – Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, diagnostic mammography. (List separately in addition to code for primary procedure)

A new CPT code 76085, “Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, screening mammography (List separately in addition to code for primary procedure)”, for computer-aided detection conversion of standard film images to digital images has been established as an add-on code that can be billed only in conjunction with the primary service screening mammography code 76092 as well as G0202. Payment will be made under the MPF .

A separate code, G0236, has been created for “Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, diagnostic mammography (List separately in addition to code for primary procedure)” for computer aided detection, and has been established as the add-on code that can be billed in conjunction with the primary service diagnostic mammography codes 76090, 76091, G0204 or G0206. (See 4601.6 for billing and payment instructions when billed in conjunction with digital or screening mammography .

B. Billing Requirements.–Only one screening mammogram, either 76092 or G0202 may be billed in a calendar year. Therefore, advise your providers not to submit claims reflecting both a film screening mammography (76092) and a digital screening mammography G0202. Also advise your providers not to submit claims reflecting HCPCS codes 76090 or 76091 (diagnostic mammography-film) and G0204 or G0206 (diagnostic mammography-digital). Deny the claim when both a film and digital screening or diagnostic mammography are reported. However, a screening and diagnostic mammography can be billed together.

C. Billing and Payment of Computer Aided Detection (CAD) Services.–Code 76085, “Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, screening mammography”, for CAD has been established as an add on code that can be billed in conjunction with primary service code G0202 as well as 76092.

There is no Part B deductible. However, coinsurance is applicable. The add-on code cannot be billed alone. Deny the claim if only the add-on code is billed.

Code G0236, “Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, diagnostic mammography”, for CAD has been established as an add on code that can be billed in conjunction with primary service code G0204 or G0206 as well as existing codes 76090 or 76091. The Part B deductible and co-insurance apply.

The add-on code cannot be billed alone. Deny the claim if only the add-on code is billed.

NOTE: Contractors should use remark code N122, “Mammography add-on code can not be billed by itself” (Effective Sept 12, 2002), when deny a claim if only the add-on code is billed.

Screening Mammography

Medicare covers one screening mammogram for women aged 40 years or older once every 12 months. CPT code 77057 (screening mammography, bilateral [two view film study of each breast]) is reported if a standard screening mammogram is performed. Medicare also covers computer aided detection (CAD) technology when performed in addition to the standard mammography. This service is reported using CPT add-on code +77052 (computer-aided detection (computer algorithm analysis of digital image data for lesion detection); screening mammography) in addition to code 77057. The Medicare deductible is waived for this service but the patient is responsible for 20% of the Medicare approved amount.

In April 2001, Medicare began to cover and provide additional payment for the use of digital technology for screening and diagnostic mammography studies. HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views) was developed to be reported for a screening full-field digital (FFDM) mammogram. Diagnosis code(s) V76.11 (screening mammogram for high-risk patient) or V76.12 (other screening mammogram) should be linked to the appropriate CPT-4 mammography code reported. The Medicare deductible is waived for this service but the patient is responsible for 20% of the Medicare approved amount.

A diagnostic mammogram (when the patient has an illness, disease or symptoms indicating the need for a mammogram) is covered whenever it is medically necessary.