Screening Mammography CPT code 77057, 77055, 77056 , 77052

 Procedure  Code  Description Site of Service


77055 Mammography; unilateral Office/Freestanding (Global) 2.52 $90.23 Facility (Professional) 1.00 $35.80 Facility (Technical) 1.52 $54.42

77056 Mammography; bilateral Office/Freestanding (Global) 3.24 $116.01 Facility (Professional) 1.24 $44.40 Facility (Technical) 2.00 $71.61

77057 Screening mammography, bilateral (2-view film study of each breast) Office/Freestanding (Global) 2.31 $82.71 Facility (Professional) 1.00 $35.80 Facility (Technical) 1.31 $46.90


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.

Computer-Aided Detection (CAD) Add-On Codes

Effective for services on or after January 1, 2002 thr ugh December 31, 2003, (or April 1, 2002 for hospitals subject to OPPS) a new Procedure code 76085, CAD 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. The definition of 76085 is: “Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, mammography (list separately in addition to code for primary procedure).”

NOTE: For claims with dates of service April 1, 2003 – December 31, 2003, code G0202 may be billed in conjunction with 76085.

Carriers and FIs make payment under the Medicare physician fee schedule. There is no Part B deductible. However, coinsurance is applicable.

For claims with dates of service April 1, 2005, and la er, hospitals bill for code 76082* (77051*) under the 13X bill type. The 14X bill type is no longer applicable. Appropriate TOBs for providers other than hospitals are 22X, 23X, and 85X.

Contractors must assure that claims containing code 76085 also contain HCPCS code 76092 or G0202. If not, FIs return claims to the provider with an explanation that payment for code 76085 cannot be made when billed alone. Carriers deny payment for 76085 when billed without 76092 or G0202.

NOTE: When screening CAD 76085 is billed in conjunction with a screening mammography (76092 or G0202) and the screening mammography (76092 or G0202) fails the age and frequency edits in CWF, both services will be rejected by CWF.

Effective with claims with dates of service January 1, 2004 thru December 31, 2006, HCPCS code 76083, “Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation with or without digitization of film radiographic images; screening mammography (list separately in addition
to code for primary procedure),” can be billed in conjunction with the primary service mammography code 76092 or G0202.

Effective with claims with dates of service January 1, 2007 and later, HCPCS code 77052, which replaces code 76083 “Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation with
or without digitization of film radiographic images; screening mammography (list separately in addition to code for primary procedure),” can be billed in conjunction with the primary service mammography code 77057 or G0202.

Contractors must assure that claims containing code 77052* (76083*) also contain HCPCS code 77057* (76092*) or G0202. FIs return claims containing code 77052* (76083*) that do not also contain HCPCS code 77057* (76092*) or G0202 with an explanation that payment for code 77052* (76083*) cannot be made when billed alone. Carriers deny payment for 77052* (76083*) when billed without 77057* (76092*) or G0202.

NOTE: When screening CAD 77052* (76083*) is billed in conjunction with a screening mammography (77057* (76092*) or G0202) and the screening mammography (77057* (76092*) or G0202) fails the age and frequency edits in CWF, both services will be rejected by CWF. *For claims with dates of service prior to January 1, 2007, providers report Procedure codes 76083 and 76092 or G0202. For claims with dates of service January 1, 2007 and later, providers report Procedure codes 77052 and 77057 or G0202, respectively.

Diagnostic Add-on Codes G0236 and 77051* (76082*) Effective for services on or after January 1, 2002 thru December 31, 2003, (or April 1, 2002 for hospital claims subject to OPPS), HCPCS code G0236 was established for diagnostic mammography CAD that can be billed only on the same claim with the primary service of either 76090 or 76091. The definition of G0236 is: “Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation.”

The code must be listed separately in addition to code for the primary procedure.

NOTE: For claims with dates of service April 1, 2003 - December 31, 2003, code G0204 and G0206 may be billed in conjunction with G0236.

For claims with dates of service April 1, 2005, and later, hospitals bill for code 76082* (77051*) under the 13X bill type. The 14X bill type is no longer applicable. Appropriate TOBs for providers other than hospitals are 22X, 23X, and 85X.

There are no frequency limitations on film or digital diagnostic tests or CAD-diagnostic tests. Contractors must assure that claims containing code G0236 also contain HCPCS code 76090, 76091, G0204, or G0206. If not, FIs return claims to the provider with an explanation that payment for code G0236 cannot be made when billed alone. Carriers deny payment for G0236 when billed without 76090, 76091, G0204, or G0206.

Effective with claims with dates of service January 1, 2004 thru December 31, 2006, HCPCS code 76082, “Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation with or without digitization of film radiographic images; diagnostic mammography (list separately in  ddition to code for primary procedure),” can be billed in conjunction with the primary service mammography code 76090, 76091, G0204, or G0206.



Effective Date: January 1, 2007

Implementation Date: January 2, 2007

I. GENERAL INFORMATION

A. Background: New 2007 Current Procedural Terminology (CPT) mammography codes have been assigned for screening and diagnostic mammography services. These codes will replace the current CPT codes; however the CPT code descriptors for the services are unchanged.

B. Policy: : Effective for claims with dates of service January 1, 2007 and later, providers report new CPT codes 77051, 77052, 77055, 77056, and 77057 in place of current CPT codes 76082, 76083, 76090, 76091, and 76092 respectively.

II. BUSINESS REQUIREMENTS Use “Shall" to denote a mandatory requirement Number Requirement Responsibility (place an “X” in each applicable column) SharedSystem



5327.1 Upon release of the 2007 CPT codes by the American Medical Association (AMA), contractors shall advise providers that effective for claims with dates of service January 1, 2007 and later, the following new CPT codes have been assigned to mammography services:

 77051  77052  77055  77056  77057

The CPT code descriptors for the services are unchanged.

X X X 5327.2 Contractors shall advise providers to report new X X X
Number Requirement Responsibility (place an “X” in each applicable column) SharedSystem  codes for mammography claims effective January 1, 2007 as follows:

• report code 77051 in place of code 76082;

•report code 77052 in place of code 76083;

• report code 77055 in place of code 76090;

• report code 77056 in place of code 76091;

• report code 77057 in place of code 76092;

5327.2.1 Contractors shall use the following type of service (TOS) for the new codes:

77051—TOS 4

77052—TOS 1

77055---TOS 4

77056---TOS 4

77057---TOS 1

X X X 5327.3 Contractors shall return to providers claims with dates of service on or after January 1, 2007, containing CPT codes 76082, 76083, 76090, 76091, or 76092. X X X X X OPPS/ OCE

5327.4 Contractors and CWF shall update their systems to discontinue CPT codes 76082, 76083, 76090, 76091, and 76092 and replace them with new CPT codes 77051, 77052, 77055, 77056, and 77057 respectively. X X X X X X

5327.5 Contractors shall update any edits in their systems that contain CPT codes 76082, 76083, 76090, 76091, 76092 to replace them with CPT codes 77051, 77052, 77055, 77056, and 77057 respectively. X X X X X X

5327.6 CWF shall apply existing frequency standards for new screening mammography CPT codes  7052 and 77057 effective January 1, 2007. X



J. Breast (Incision, Excision, Introduction, Repair and Reconstruction)

1. Since a mastectomy (CPT codes 19300-19307) describes removal of breast tissue including all lesions within the breast tissue, breast excision codes (19110-19126) generally are not separately reportable unless performed at a site unrelated to the mastectomy. However, if the breast excision procedure precedes the mastectomy for the purpose of obtaining tissue for pathologic examination which determines the need for the mastectomy, the breast excision and mastectomy codes are separately reportable.

(Modifier 58 may be utilized to indicate that the procedures were staged.) If a diagnosis was established preoperatively, an excision procedure for the purpose of obtaining additional pathologic material is not separately reportable.

Similarly, diagnostic biopsies (e.g., fine needle aspiration, core, incisional) to procure tissue for diagnostic purposes to determine whether an excision or mastectomy is necessary at the same patient encounter may be reported with modifier 58 appended to the excision or mastectomy code. However, biopsies (e.g.,Revision Date (Medicare): 1/1/2014 III-11 fine needle aspiration, core, incisional) are not separately reportable if a preoperative diagnosis exists.



2. The breast procedure codes include incision and closure. Some codes describe mastectomy procedures with  ymphadenectomy and/or removal of muscle tissue. The latter procedures are not separately reportable. Except for sentinel lymph node biopsies, ipsilateral lymph node excisions are not separately reportable. Contralateral lymph node excisions may be
separately reportable with appropriate modifiers (i.e., LT, RT).




3. Sentinel lymph node biopsy is separately reportable when performed prior to a localized excision of breast or a mastectomy without lymphadenectomy. However, sentinel lymph node biopsy is not separately reportable with a mastectomy procedure that includes lymphadenectomy in the anatomic area of the sentinel lymph node biopsy. Open biopsy or excision of sentinel lymph node(s) should be reported as follows: axillary (CPT codes 38500 or 38525), deep cervical (CPT code 38510), internal mammary (CPT code 38530). (CPT code 38740(axillary lymphadenectomy; superficial) should not be reported for a sentinel lymph node biopsy. Sentinel lymph node biopsy of superficial axillary lymph node(s) is correctly reported as CPT code 38500 (biopsy or excision of lymph node(s), superficial) which includes the removal of one or more discretely identified superficial lymph nodes. By contrast a superficial axillary lymphadenectomy (CPT code 38740) requires removal of all superficial axillary adipose tissue with all lymph nodes in this adipose tissue.)



4. Breast reconstruction codes that include the insertion of a prosthetic implant should not be reported with codes that separately describe the insertion of a breast prosthesis.

5. CPT codes for breast procedures generally describe unilateral procedures.

6. If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed withmammographic guidance (e.g., 19281,19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.

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