CPT code 77051, 77055, G0204, G0206 - Mammography, Diagnostic

procedure code and description

G0204 -Diagnostic mammography, producing direct digital image, bilateral, all views. - average fee payment -  $150 -$180


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

77051 - 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


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.


Use procedure codes 77051, 77055, 77056, G0204 and G0206 to report only diagnostic mammography. The conditions in the “Covered Diagnoses” section are considered the medical indications for diagnostic mammography.



CPT/HCPCS Codes for Screening Mammography

* 77052 (in conjunction with 77057): Computer-aided 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).

* 77057 (in conjunction with 77052): Screening mammography, bilateral (2-view film study of each breast) for computer-aided detection applied to a screening mammogram.

* G0202: Screening mammography, producing direct digital image, bilateral, all views.

Diagnostic mammography checks for breast cancer after the discovery of a lump or other sign or symptom of breast cancer. These signs may include pain, skin thickening, nipple discharge, or a change in breast size or shape. Diagnostic mammography is not a preventive service.

CPT/HCPCS Codes for Diagnostic Mammography

* 77051 (in conjunction with 77055 or 77056): 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 addition to code for primary procedure)

* 77055 (in conjunction with 77051 for computer-aided detection applied to a diagnostic mammogram): Mammography; unilateral.

* 77056 (in conjunction with 77051 for computer-aided detection applied to a diagnostic mammogram): Mammography; bilateral.

* G0204 Diagnostic mammography, producing direct digital image, bilateral, all view.

* G0206 Diagnostic mammography, producing direct digital image, unilateral, all views.


Providers should use code 77052 in conjunction with code 77057 and code 77051 with code 77056 when billing for mammography screenings.



Patients will present themselves to the health care system under a number of different circumstances, and it will be incumbent upon the patient and treating physician/Non-Physician Practitioner (NPP) to formulate an appropriate imaging treatment plan. In some situations, a screening mammogram will apply, and, in others, a diagnostic mammogram will apply. The treating physician/NPP should ask the following four questions to assist them in determining the most appropriate type of mammogram to order:


  • Do you have breast implants?
  • Is this a follow-up to an abnormal mammogram?
  • Do you have any breast problem, such as a lump or discharge?
  • Have you ever had breast cancer?

No = screening Yes = diagnostic
If any answer to any of the questions above is Yes, the treating physician/NPP should optimally order a diagnostic mammogram. The performing facility (IDTF, hospital, etc.) should perform the test that is ordered by the treating physician/NPP.




Medicare LCD update

Based on change request (CR) 9982 (ICD-10 Coding Revisions to National Coverage Determination [NCDs]), the local coverage determination (LCD) was revised to add ICD-10-CM diagnosis code Z86.000 for Healthcare Common Procedure Coding System (HCPCS) codes G0204, G0206, and G0279.


Coverage Indications, Limitations, and/or Medical Necessity

    Screening Mammogram

    A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection breast cancer,and includes a physician’s interpretation of the results of the procedure. A screening mammogram does not require a physician’s referral, however, detection of a radiographic abnormality, may prompt the interpreting radiologist to order additional views on the same day. When this is the case, the mammography is no longer considered to be a screening exam and should be reported as a diagnostic mammogram. Radiologists who order additional tests must refer back to the treating physician or qualified non-physician practitioner for his/her UPIN and report back to the treating physician the condition of the patient. No separate reimbursement will be made for additional views. The cost for additional views is included in the cost of the diagnostic mammography service. Screening mammogram(s) (digital and non-digital) for the following indications are allowed:


        Asymptomatic women ages 40 and older are eligible for a screening mammography (digital and non-digital) performed after at least 11 months have passed following the month in which the last screening mammography was performed.

        Women between the ages of 35 and 39 are eligible to receive one baseline screening mammogram.

        Women with breast implants are eligible for screening mammography when the screening mammogram is performed within the aforementioned age and frequency limitations.

        Services will only be allowed if supplied by certified suppliers or FDA-certified mammography centers.


    Limitations


        The screening mammogram must be, at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast.

        Payment may not be made for a screening mammography performed on a woman under age 35.
        Payment may be made for only one screening mammography performed on a woman over age 34, but under age 40.

        Screening mammograms performed prior to 11 months lapsing following the month in which the last screening mammography service was rendered is noncovered.

        Facilities that perform screening mammography services may not release screening mammography x-rays for interpretation to physicians who are not approved under the facility’s certification number unless the patient has requested a transfer of the films from one facility to another for a second opinion or the patient has moved to another part of the country where the next screening mammography will be performed.


    Diagnostic Mammography

    A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician’s interpretation of the results of the procedure.

    Diagnostic mammogram(s) are allowed for the following indications:

    -the patient is under the care of the referring/ordering physician or qualified non-physician practitioner;

    -there are signs and/or symptoms suggestive of malignancy (mass, some types of spontaneous nipple discharge or skin changes);

    -there are possible radiographic abnormalities detected on screening mammography;

    -there is short interval follow-up (less than one year) necessary for unresolved clinical/radiographic concerns; or

    -follow-up of established history of a malignancy is necessary

    Diagnostic breast evaluation may be indicated in cases of a personal history of malignancy and in cases of benign biopsy-proven breast disease. These diagnoses should not, however, routinely warrant a diagnostic mammography.

    A breast implant does not necessarily imply that a mammogram is diagnostic in nature. Although additional views may be needed, these additional views do not necessarily constitute a diagnostic mammogram, unless there are specific findings that require investigation.

    Medicare Part B covers diagnostic mammography services if they are furnished by a facility that meets the certification requirements of section 354 of the Public Health Service Act (PHS Act), as implemented by 21 CFR part 900, subpart B. As of October 1, 1994, the Mammography Quality Standards Act requires that all mammography centers that bill Medicare be certified by the Food and Drug Administration (FDA). Only FDA-certified mammography centers will be reimbursed.

    A physician (or qualified non-physician practitioner) referral is required for diagnostic mammography. The patient must be under the care of the physician (or qualified non-physician practitioner) who orders the procedure. The order should specify the diagnosis prompting the referral for a diagnostic mammogram.

    Diagnostic mammography should be performed under the direct, on-site supervision of an interpreting physician qualified in mammography. Diagnostic mammography may require that the performing radiologist review the history with the patient, review the prior mammograms, and perform an examination as part of the mammography. Also, the findings of the examination are typically discussed with the patient at the completion of the mammogram. Therefore, if telemammography is being used with digital diagnostic mammography, the radiologist need not be present for the mammography; however, he/she must be available to discuss the history with the patient, examine the patient, and discuss results of the findings of the examination with the patient within an acceptable period of time.

    Limitations

    This policy does not outline complete indications and limitations of breast ultrasound but addresses the limitations of screening mammography with breast ultrasound. (There is no Medicare benefit.)

    Breast ultrasound is not a Medicare preventive services benefit. Therefore, routine breast cancer screening with ultrasound (including patients with dense breast tissue) is not a Medicare covered service. Clinical evidence has not yet demonstrated that routine use of ultrasonography as an adjunct to screening mammography reduces the mortality rate from breast cancer.

    Breast ultrasonography may be reasonable and necessary in addition to a diagnostic mammography for the evaluation of some ambiguous mammographic or palpable masses, focal asymmetry, or dense breast tissue that may represent or mask a mass. Breast ultrasonography may also be performed for non-palpable masses, detected by mammography, to differentiate cysts from solid lesions.

    Breast ultrasound is medically reasonable and necessary as an aid for radiologists to localize breast lesions and in guiding placement of instruments for cyst aspiration and percutaneous breast biopsies. (This is not an all-inclusive list.) If breast ultrasound is medically reasonable and necessary and done on the same day as a screening mammography, the screening mammography becomes diagnostic.

    The request (order) for the ultrasound examination must be originated by a treating physician/NPP. This requirement is not applicable to hospital based radiologists for inpatient or outpatient breast ultrasound.

    A radiologist performing a therapeutic interventional procedure is considered a treating physician. A radiologist performing a diagnostic interventional or diagnostic procedure is not considered a treating physician.

    If the testing facility has no order for breast ultrasound and cannot reach the treating physician/practitioner to obtain a new order for the addition of breast ultrasound when needed and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criteria apply:


        The testing center performs the mammography ordered by the treating physician/practitioner;

        The interpreting physician at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary;

        Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the beneficiary;

        The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary; and

        The interpreting physician at the testing facility documents in his/her report why additional testing was done.


    Breast sonography should be performed under the general supervision of a physician qualified in breast ultrasonography.


    The ultrasound study must have a permanent written record along with the accompanying set of images in retrievable image storage format. The images and report should become a part of the patient’s permanent medical record.


Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.


Procedure codes and Description

77051© 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 addition to code for primary procedure)

77055© Mammogram, one breast

77056© Mammogram, both breasts

G0204 Diagnostic mammography, direct digital image, bilateral, all views

G0206 Diagnostic mammography, direct digital image, unilateral, all views

Billing and Coding Guidelines
New Modifier GG - Performance and payment of a screening mammogram and diagnostic mammography on the same patient, same day.

NOTE: Modifier GG should be used to show that the diagnostic test performed on the same date as the screening test is appropriate. This modifier is for tracking purposes only. 

HCPCS code G0204, Diagnostic mammography, direct digital image, bilateral, all  views. Payment will be the lesser of the provider's charge or the amount that will be provided for this code in the pricing file. (That amount is 150 percent of the locality specific amount paid under the physician fee schedule for the technical component (TC) of Procedure code 76091, the code for a bilateral diagnostic mammogram.) Twenty percent of the lower of charge or 150 percent of MPFS. 

Deductible is applicable. Coinsurance will equal 20 percent of the lesser of the actual charge or 150 percent of the locality specific payment of Procedure code 76091. 

HCPCS code G0206, Diagnostic mammography, direct digital image, unilateral, all views. Payment will be made based on the same amount that is paid to the provider, under the payment method applicable to the specific provider type (i.e., hospital, rural health clinic, etc.) for Procedure code 76090, the code for a mammogram, one breast. For example, this service, when furnished as a hospital outpatient service, will be paid the amount under the outpatient prospective payment system (OPPS) for Procedure code 76090. Deductible applies. Coinsurance is the national unadjusted coinsurance for the APC wage adjusted for the specific hospital. 

o HCPCS code G0207, Diagnostic mammography, film processed to produce digital image analyzed for potential abnormalities, unilateral, all view. Payment will be based on the same amount that is paid to the provider, under the payment method applicable to the specific provider type (i.e., hospital, rural health clinic) for Procedure code 76090, the code for mammogram, one breast. 

For example, this service, when furnished as a hospital outpatient service, will be paid the amount payable under the OPPS for Procedure code 76090. Deductible applies. Coinsurance is the national unadjusted coinsurance for the APC wage adjusted for the specific hospital.

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.


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

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 addition to code for primary procedure),” can be billed in conjunction with the primary service mammography code 76090, 76091, G0204, or G0206.

Effective for claims with dates of service January 1, 2007 and later, HCPCS code 77051, which replaces 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 addition to code for primary procedure),” can be billed in conjunction  with the primary service mammography code 77055, 77056, G0204, or G0206.

Contractors must assure that claims containing code 77051* (76082*) also contain HCPCS codes 77055*(76090*), 77056* (76091*), G0204 or G0206. FIs return claims containing code 77051* (76082*) that do not also contain HCPCS code 77055* (76090*), 77056* (76091*), G0204, or G0206 with an explanation that payment for code 77051* (76082*), cannot be made when billed alone. Carriers deny payment for 77051* (76082*) when billed without 77055* (76090*), 77056* (76091*), G0204, or G0206.

*For claims with dates of service prior to January 1, 2007, providers report CPT codes 76090, 76091, G0204 or G0206 with 76082. For claims with dates of service January 1, 2007 and later, providers report CPT codes 77055, 77056, G0204, or G0206 with 77051, respectively.

*For claims with dates of service prior to January 1, 2007, providers report CPT codes 76090, 76091, G0204 or G0206 with 76082. For claims with dates of service January 1, 2007 and later, providers report CPT codes 77055, 77056, G0204, or G0206 with 77051, respectively.

Payment for computer add-on diagnostic mammogram HCPCS code G0236 or 77051* (76082*) when billed with CPT code 77055* (76090*), 77056* (76091*), G0204, or G0206 is as follows:

Place/Provider of Service Payment Physician Medicare physicians’ fee schedule Outpatient Hospital Outpatient Prospective Payment System (OPPS) Critical Access Hospital (CAH) Reasonable Cost SNF Medicare physicians’ fee schedule – technical component

Independent RHC All-inclusive rate for professional component (codes 76090 and 76091)** Freestanding FQHC All-inclusive rate for professional component (codes 76090 and 76091)** ** Only for dates of service prior to April 1, 2005.

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 coinsurance apply. HCPCS code G0236 is deleted as of December 31, 2003.

Effective for claims with dates of service January 1, 2004 thru December 31, 2006, add-on 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 addition to code for primary procedure),” can be billed in conjunction with primary service codes G0204 or G0206 as well as codes 76090 or 76091. The Part B deductible and coinsurance apply.

Except as provided in the following sections for RHCs and FQHCs, the following procedures apply to billing for screening mammographies.

The technical component portion of the screening mammography is billed on Form CMS- 1450 under bill type 12X, 13X, 14X**, 22X, 23X or 85X using revenue code 0403 and HCPCS code 77057* (76092*).

The technical component portion of the diagnostic mammography is billed on Form CMS- 1450 under bill type 13X, 14X**, 22X, 23X or 85X using revenue code 0401 and HCPCS code 77055* (76090*), 77056* (76091*), G0204 and G0206.

Separate bills are required for claims with dates of service prior to January 1, 2002. Providers include on the bill only charges for the mammography screening. Separate bills are not required for claims with dates of service on or after January 1, 2002. See separate instructions below for rural health clinics (RHCs) and federally qualified health centers (FQHCs).

Add-on CAD Code 76082 must be billed in conjunction with diagnostic mammography code 76090, 76091, G0204, or G0206 for claims with dates of service on or after January 1, 2004 through December 31, 2006. For claims with dates of service January 1, 2007 and later, add- on CAD code 77051 must be billed in conjunction with diagnostic mammography codes 77055,77056, G0204 and G0206. Use Type of Service “4”.

The claim should be prepared for FI processing reflecting the diagnostic revenue code (0401) along with HCPCS code 76090, 76091, G0204, G0206 or G0236 as appropriate and modifier “-GH” “Diagnostic mammogram converted from screening mammogram on same day.” Statistics will be collected based on the presence of modifier “-GH.” A separate claim is not required. Regular billing instructions remain in place for mammograms that do not fit this situation.

FIs require the diagnostic claim be prepared reflecting the diagnostic revenue code (0401) along with HCPCS code 77055* (76090*), 77056* (76091*), G0204, G0206 or G0236 and modifier “-GG” “Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day.” Reporting of this modifier is needed for data collection purposes. Regular billing instructions remain in place for a screening mammography that does not fit this situation.

Only one screening mammogram, either 77057* (76092*) or G0202, may be billed in a calendar year. Therefore, providers/suppliers must not submit claims reflecting both a film screening mammography (77057* (76092*)) and a digital screening mammography G0202. Also, they must not submit claims reflecting HCPCS codes 77055* (76090*) or 77056* (76091*) (diagnostic mammography-film) and G0204 or G0206 (diagnostic mammographydigital). Contractors deny the claim when both a film and digital screening or diagnostic mammography is reported. However, a screening and diagnostic mammography can be billed together.

Providers bill for the technical portion of screening and diagnostic mammograms on Form CMS-1450 under bill type 13X, 22X, 23X, or 85X. The professional component is billed to the carrier on Form CMS-1500 (or electronic equivalent). Providers bill for digital screening mammographies on Form CMS-1450, utilizing revenue code 0403 and HCPCS G0202 or G0203. Providers bill for digital diagnostic mammographies on Form CMS-1450, utilizing revenue code 0401 and HCPCS G0204, G0205, G0206 or G0207

Diagnostic Mammography

A diagnostic mammography is a radiological mammogram and is a covered diagnostic test under the following conditions:
• A patient has distinct signs and symptoms for which a mammogram is indicated;
• A patient has a history of breast cancer

Prior to April 1, 2003, the MQSA file showed all facilities that are certified to perform film screening and diagnostic mammograms. After April 1, 2003, the file shows a new Record Type with two indicators, “1” for film and “2” for digital to determine which mammograms the facility is certified to perform.

Effective for claims with dates of service January 1, 2015 and later, HCPCS code 77063, “Screening Digital Breast Tomosynthesis, bilateral, must be billed in conjunction with the primary service mammogram code G0202.

Medicare will pay for a diagnostic mammogram when one of the following conditions is met:
• A patient has distinct signs and symptoms for which a mammogram is indicated
• A patient has a history of breast cancer
• A patient is asymptomatic but, on the basis of the patient’s history and other factors the physician considers significant, the physician's judgment is that a mammogram is appropriate

Mammography Coverage guidelines from BCBS

Screening (preventive) mammograms

 A screening mammogram is a routine test that your doctor may recommend on a regular basis (e.g. every year, every other year, etc.) based on your health status. As part of our preventive care benefit, there is no copayment when women:

• 40 years of age or older have an annual screening mammogram; or

• aged 35-39 with no history of breast cancer have one baseline screening during that period of time; or

• of any age with prior history of breast cancer or a first degree relative with a prior history of breast cancer have an annual screening mammogram.

 Diagnostic mammograms

 When a doctor indicates a medical diagnosis on the bill, it is a diagnostic mammogram. This often occurs when the doctor orders a follow-up mammogram after the screening mammogram because of a possible finding. Diagnostic mammograms are not part of your preventive service benefit so copayment, deductible, or other cost-share requirements for your plan will apply.

A prescription is required

 The state of New York requires a prescription for mammography screening. Be sure to obtain a prescription from your doctor for the test before your screening. You will be required to present the prescription at your scheduled appointment time.


Mammograms:

The following codes are covered for BlueCHiP for Medicare and Commercial members: 77051, 77052, 77055, 77056, 77057 The following codes are covered for BlueCHiP for Medicare members: Note: These codes are intended for use when filing claims for BlueCHiP for Medicare only. Claims for Commercial products should be filed with the appropriate CPT code. G0202, G0204, G0206 Pap Smears:

The following codes are covered for BlueCHiP for Medicare and Commercial members: 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175 The following codes are covered for BlueCHiP for Medicare members: Note: These codes are intended for use when filing claims for BlueCHiP for Medicare only. Claims for Commercial products should be filed with the appropriate CPT code. G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148 BlueCHiP for Medicare and Commercial Products The following codes are covered but not separately reimbursed: G0101, Q0091, P3000, P3001

ICD-10 Codes that Support Medical Necessity
    
    For screening mammography (77057, 77063 or G0202):

    For claims with dates of service on or after January 1, 2002, when a screening mammography and a diagnostic mammography are performed on the same date of service, for the same patient, append modifier -GG to the diagnostic mammography procedure code. Both the screening mammography and the diagnostic mammography procedure codes should be reported on the same claim:

    Group 1 Codes

    Z12.31* Encounter for screening mammogram for malignant neoplasm of breast
    Group 2 Paragraph
    For diagnostic mammography (77055, 77056, G0204, G0206 or G0279) billed with or without Modifier GG:


    Group 2 Codes

    C43.52 Malignant melanoma of skin of breast

    C43.59 Malignant melanoma of other part of trunk

    C44.501 Unspecified malignant neoplasm of skin of breast

    C44.509 Unspecified malignant neoplasm of skin of other part of trunk

    C44.511 Basal cell carcinoma of skin of breast
    C44.519 Basal cell carcinoma of skin of other part of trunk

    C44.521 Squamous cell carcinoma of skin of breast

    C44.529 Squamous cell carcinoma of skin of other part of trunk

    C44.591 Other specified malignant neoplasm of skin of breast

    C44.599 Other specified malignant neoplasm of skin of other part of trunk

    C45.9 Mesothelioma, unspecified
    C50.011 Malignant neoplasm of nipple and areola, right female breast

    C50.012 Malignant neoplasm of nipple and areola, left female breast

    C50.019 Malignant neoplasm of nipple and areola, unspecified female breast

    C50.021 Malignant neoplasm of nipple and areola, right male breast

    C50.022 Malignant neoplasm of nipple and areola, left male breast

    C50.029 Malignant neoplasm of nipple and areola, unspecified male breast

    C50.111 Malignant neoplasm of central portion of right female breast

    C50.112 Malignant neoplasm of central portion of left female breast

    C50.119 Malignant neoplasm of central portion of unspecified female breast

    C50.121 Malignant neoplasm of central portion of right male breast

    C50.122 Malignant neoplasm of central portion of left male breast

    C50.129 Malignant neoplasm of central portion of unspecified male breast

    C50.211 Malignant neoplasm of upper-inner quadrant of right female breast

    C50.212 Malignant neoplasm of upper-inner quadrant of left female breast

    C50.219 Malignant neoplasm of upper-inner quadrant of unspecified female breast

    C50.221 Malignant neoplasm of upper-inner quadrant of right male breast

    C50.222 Malignant neoplasm of upper-inner quadrant of left male breast

    C50.229 Malignant neoplasm of upper-inner quadrant of unspecified male breast


    C50.311 Malignant neoplasm of lower-inner quadrant of right female breast



Diagnosis codes for a diagnostic mammography will vary according to diagnosis. 

Diagnoses for Services October 1, 1997 Through December 31, 1997 On every screening mammography claim where the patient is not a high-risk individual, diagnosis code V76.12 is reported on the claim. If the screening is for a high risk individual, the provider reports the principal diagnosis code as V76.11 - “Screening mammogram for high risk patient.”

In addition, for high-risk individuals, one of the following applicable diagnoses codes is reported as “Other Diagnoses codes” (Form CMS-1450, FL 68)

• V10.3 “Personal history - Malignant neoplasm female breast”;
• V16.3 “Family history - Malignant neoplasm breast”; or
• V15.89 “Other specified personal history representing hazards to health.”

The following chart indicates the ICD-9 diagnosis codes reported for each high-risk category: High Risk Category Appropriate Diagnosis Code

A personal history of breast cancer V10.3

A mother, sister, or daughter who has breast cancer V16.3

Payment for the technical component equals 80 percent of the least of :

• The actual charge for the technical component (HCPCS code 77057* (76092*)) of the service;
• The physicians’ fee schedule amount for the technical component of HCPCS code 77056* (76091*) (a bilateral diagnostic mammogram); or
• The technical portion of the screening mammography limit as identified in the chart above.

*For claims with dates of service prior to January 1, 2007, providers report CPT codes

76091 and 76092. For claims with dates of service January 1, 2007 and later, providers report CPT codes 77056 and 77057 respectively. Carrier Payment - Technical Component Payment for the technical component equals 80 percent of the least of:
• The actual charge for the technical component of the service;
• The amount determined with respect to the technical component for the service under Medicare Physicians’ Fee Schedule; or
• The technical portion of the screening mammography limit as identified in the chart above
Payment for Computer Add-On Diagnostic and Screening Mammograms for FIs and Carriers (Rev.1070, Issued: 09-29-06, Effective: 01-01-07, Implementation: 01-02-07)
Payment for computer add-on diagnostic mammogram HCPCS code G0236 or 77051* (76082*) when billed with CPT code 77055* (76090*), 77056* (76091*), G0204, or G0206 is as follows:
Place/Provider of Service Payment
Physician Medicare physicians’ fee schedule
Outpatient Hospital Outpatient Prospective Payment System (OPPS)
Critical Access Hospital (CAH) Reasonable Cost SNF Medicare physicians’ fee schedule – technical component

Effective for claims with dates of service January 1, 2007 and later, add-on HCPCS code 77051, “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 addition to code for primary procedure),” can be billed in conjunction with primary service codes G0204 or G0206 as well as codes 77055 or 77056. The Part B deductible and coinsurance apply.

The add-on code cannot be billed alone. FIs return to provider claims containing only codes G0236 or 77051* (76082*) with an explanation that payment for code G0236 or 77051* (76082*) cannot be made when billed alone.

Carriers deny the claim using remark code N122, “Mammography add-on code can not be billed by itself” (effective September 12, 2002).

Payment for computer add-on screening mammogram HCPCS code 76085 or 77052* (76083*) when billed with CPT code 77057* (76092*) or G0202 is as follows:

Place/Provider of Service Payment
Physician Medicare physicians’ fee schedule
Outpatient Hospital Medicare physicians’ fee schedule
Critical Access Hospital (CAH) Reasonable Cost
SNF Medicare physicians’ fee schedule – technical component
Independent RHC All-inclusive rate for professional component (code 76092**)
Freestanding FQHC All-inclusive rate for professional component (code 76092**)
** Only for dates of service prior to April 1, 2005.

Claims With Dates of Service October 1, 1998 Through December 31, 2001

A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while the beneficiary is still at the facility for the screening exam. Where a radiologist interpretation results in additional films, the mammography is no longer considered a screening exam for application of age and frequency standards or for payment purposes. This can be done without an additional order from the treating physician. When this occurs, the claim will be billed and paid as a diagnostic mammography instead of a screening mammography. However, since the original intent for the exam was for screening, for statistical purposes, the  claim is considered a screening.

The claim should be prepared for FI processing reflecting the diagnostic revenue code (0401) along with HCPCS code 76090, 76091, G0204, G0206 or G0236 as appropriate and modifier “-GH” “Diagnostic mammogram converted from screening mammogram on same day.” Statistics will be collected based on the presence of modifier “-GH.” A separate claim is not required. Regular billing instructions remain in place for mammograms that do not fit this situation.

Carriers should receive a claim for a screening mammogram with CPT code 76092 (screening mammography, bilateral) (Type of Service = 1) but, if the screening mammogram turns into a diagnostic mammogram, the claim is billed with CPT code 76090 (unilateral) or  76091 (bilateral), (TOS= 4), with the “-GH” modifier. Carriers pay the claim as a diagnosticmammography instead of a screening mammography.

NOTE: However, the ordering of a diagnostic test by a radiologist following a screening test that shows a potential problem need not be on the same date of service.

In this case, where additional diagnostic tests are performed for the same beneficiary, same visit on the same day, the UPIN of the treating physician is needed on the carrier claim. The radiologist must refer back to the treating physician for his/her UPIN and also report to the treating physician the condition of the patient. Carriers need to educate radiologists and treating physicians that the treating physician’s UPIN is required whenever a physician refers or orders a diagnostic lab or radiology service. If no UPIN is present for the diagnostic mammography code, the carrier will reject the claim.

Claims With Dates of Service On or After January 1, 2002, (or On or After April 1, 2002 for Hospitals Subject to OPPS)

A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the screening exam. When a radiologist’s interpretation results in additional films, Medicare will pay for both the screening and diagnostic mammogram.




ICD-9-CM Codes That Support Medical Necessity
The Procedure/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified Procedure/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for Procedure/HCPCS codes 77051, 77055, 77056, G0204 and G0206:
Covered for:

172.5
Malignant melanoma of skin of trunk, except scrotum
173.5
Other malignant neoplasm of skin of trunk, except scrotum
174.0–174.6
Malignant neoplasm of female breast
174.8–174.9
Malignant neoplasm of female breast
175.0
Malignant neoplasm of male breast, nipple and areola
175.9
Malignant neoplasm of male breast, other and unspecified sites
198.2
Secondary malignant neoplasm of skin
198.81
Secondary malignant neoplasm of breast
199.0–199.1
Malignant neoplasm without specification of site
216.5
Benign neoplasm of skin of trunk, except scrotum
217
Benign neoplasm of breast
232.5
Carcinoma in situ of skin of trunk, except scrotum
233.0
Carcinoma in situ of breast
238.2–238.3
Neoplasm of uncertain behavior of other and unspecified sites and tissues
239.1–239.3
Neoplasm of unspecified nature
239.6–239.7
Neoplasm of unspecified nature
451.89
Phlebitis and thrombophlebitis of other sites (breast)
610.0–610.4
610.8–610.9
Benign mammary dysplasias
611.0–611.6
Other disorders of breast
611.71–611.72
Signs and symptoms in breast
611.79
Other signs and symptoms in breast
611.83
Capsular contracture of breast implant
611.89
Other specified disorders of breast
611.9
Unspecified breast disorder
729.6
Residual foreign body in soft tissue
729.90–729.92
Disorders of soft tissue, unspecified
729.99
Other disorders of soft tissue
793.80–793.82
Nonspecific abnormal findings on radiological and other examinations of body structure, breast
793.89
Other (abnormal) findings on radiological examination of breast
793.91
Image test inconclusive due to excess body fat
879.0–879.1
Open wound of breast
959.11–959.12
Injury, other and unspecified, trunk
959.19
Other injury of other sites of trunk
996.54
Mechanical complication of breast prosthesis
996.69
Infection and inflammatory reaction due to other internal prosthetic device, implant and graft
V10.3
Personal history of malignant neoplasm of breast
V43.82
Breast replacement status
V50.1
Other plastic surgery for unacceptable cosmetic appearance (including breast augmentation and reduction)
V71.1
Observation for suspected malignant neoplasm (lesion)




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