G0204 -Diagnostic mammography, producing direct digital image, bilateral, all views. - average fee payment - $150 -$180
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.
- 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?
Coverage Indications, Limitations, and/or Medical Necessity
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.
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.
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.
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.
- 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.
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)
Mammogram, one breast
Mammogram, both breasts
Diagnostic mammography, direct digital image, bilateral, all views
Diagnostic mammography, direct digital image, unilateral, all views
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
ICD-9-CM Codes That Support Medical Necessity
Malignant melanoma of skin of trunk, except scrotum
Other malignant neoplasm of skin of trunk, except scrotum
Malignant neoplasm of female breast
Malignant neoplasm of female breast
Malignant neoplasm of male breast, nipple and areola
Malignant neoplasm of male breast, other and unspecified sites
Secondary malignant neoplasm of skin
Secondary malignant neoplasm of breast
Malignant neoplasm without specification of site
Benign neoplasm of skin of trunk, except scrotum
Benign neoplasm of breast
Carcinoma in situ of skin of trunk, except scrotum
Carcinoma in situ of breast
Neoplasm of uncertain behavior of other and unspecified sites and tissues
Neoplasm of unspecified nature
Neoplasm of unspecified nature
Phlebitis and thrombophlebitis of other sites (breast)
Benign mammary dysplasias
Other disorders of breast
Signs and symptoms in breast
Other signs and symptoms in breast
Capsular contracture of breast implant
Other specified disorders of breast
Unspecified breast disorder
Residual foreign body in soft tissue
Disorders of soft tissue, unspecified
Other disorders of soft tissue
Nonspecific abnormal findings on radiological and other examinations of body structure, breast
Other (abnormal) findings on radiological examination of breast
Image test inconclusive due to excess body fat
Open wound of breast
Injury, other and unspecified, trunk
Other injury of other sites of trunk
Mechanical complication of breast prosthesis
Infection and inflammatory reaction due to other internal prosthetic device, implant and graft
Personal history of malignant neoplasm of breast
Breast replacement status
Other plastic surgery for unacceptable cosmetic appearance (including breast augmentation and reduction)
Observation for suspected malignant neoplasm (lesion)