CPT code 77052, 77057, 77063 and G0202, ICD 10 Z12.31

Screening Mammography

Update: Medicare now requires an add-on code when you furnish a mammography using 3-D mammography in conjunction with a 2-D digital mammography, effective January 1, 2015.

HCPCS/CPT Codes

77052 – Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation; screening mammography (List separately in addition to code for primary procedure)

77057 – Screening mammography, bilateral (2-view film study of each breast)

77063 – Screening digital breast tomosynthesis; bilateral (List separately in addition to code for primary procedure) (Use this as an add-on code to G0202 when tomosynthesis is used in addition to 2-D mammography) - average fee payment - $50 - $60

G0202 – Screening mammography, producing direct 2-D digital image, bilateral, all views NOTE: If billing a screening mammogram and a diagnostic mammogram on the same day,

use modifier –GG to show a screening mammogram turned into a diagnostic mammogram.


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.

 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.

Digital Breast Tomosynthesis

In the CY 2015 PFS Final Rule with comment period, CMS established a payment rate for the newly created CPT code 77063 for screening digital breast tomosynthesis mammography. The same policies that are applicable to other screening mammography codes are applicable to CPT code 77063. In addition, since this is an add-on code it should only be paid when furnished in conjunction with a 2D digital  mammography.

Effective January 1, 2015, HCPCS code 77063 (Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure)), must be billed in conjunction with the screening mammography HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views, 2D imaging only. Effective January 1, 2015, beneficiary coinsurance and deductible does not apply to claim lines with 77063 (Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure).

Payment for 77063 is made only when billed with an ICD-9 code of V76.11 or V76.12 (and when ICD-10 is effective with ICD-10 code Z12.31). When denying claim lines for 77063 that are submitted without the appropriate diagnosis code, the claim lines are denied using the following messages:

** CARC 167: This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

** RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.mcd.search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.


Group Code CO (if GZ modifier present) or PR (if modifier GA is present).

On institutional claims:

** MACs will pay for tomosynthesis, HCPCS code 77063, on TOBs 12X, 13X, 22X, 23X based on MPFS, and TOB 85X with revenue code other than 096x, 097x, or 098x based on reasonable cost. TOB 85X claims with revenue code 096x, 097x, or 098x are paid based on MPFS (115% of the lesser of the fee schedule amount and submitted charge).

** MACs will pay for tomosynthesis, HCPCS code 77063 with revenue codes 096X, 097X, or 098X when billed on TOB 85X Method II based on 115% of the lesser of the fee schedule amount or submitted charge.

** MACs will return to the provider any claim submitted with tomosynthesis, HCPCS code 77063 when the TOB is not 12X, 13X, 22X, 23X, or 85X.

** MACs will pay for tomosynthesis, HCPCS code 77063, on institutional claims TOBs 12X, 13X, 22X, 23X, and 85X when submitted with revenue code 0403 and on professional claims TOB 85X when submitted with revenue code 096X, 097X, or  098X.

  ** Effective for claims with dates of service on or after January 1, 2015, MACs will RTP claims for HCPCS code 77063 that are not submitted with revenue code 0403, 096X, 097X, or 098X.


Billing and Coding Guidelines

Breast Tomosynthesis

77061 Digital breast tomosynthesis; unilateral

77062 bilateral
(Do not report 77061, 77062 in conjunction with 76376, 76377, 77057)

+77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)

(Do not report 77063 in conjunction with 76376, 76377, 77055, 77056)

(Use 77063 in conjunction with 77057)


Multiple radiology societies requested three new Category I codes to describe diagnostic (77061 and 77062) and screening (77063) digital breast tomosynthesis procedures. Current mammography codes do not include the added physician work or practice expense involved in digital breast tomosynthesis and, therefore, new codes were needed to describe these additional resources. Currently under the CMS FAQ issued in November 2013, tomosynthesis is not separately billable. The publication of Medicare’s Final Rule for 2015 this November will, we hope, clarify billing for tomosynthesis.


The Health Plan considers 3D rendering of imaging studies to be a technology and technique improvement that represents an aid to the physician via computer generated real-time study interpretation and decision support. These visual enhancements are considered an elective component of the overall imaging study performed. Therefore, separate visual enhancements reported with CPT codes 76376 and 76377 are not eligible for separate reimbursement.

The Health Plan also considers digital breast tomosynthesis (DBT) to be a visual enhancement technique   therefore CPT codes 77061, 77062 and 77063 and Healthcare Common Procedure Coding System (HCPCS Level II) code G0279 are not eligible for reimbursement


This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: 77061, 77062, 77063, G0279



ICD-10-CM Codes
Z12.31

Who Is Covered
All female Medicare beneficiaries aged 35 and older

Frequency

• Aged 35 through 39: One baseline; or
• Aged 40 and older: Annually

Beneficiary Pays

Copayment/coinsurance waived
• Deductible waived


G0202  Screening mammography, producing direct digital image, bilateral, all views. Code Effective April 1, 2001.

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. 



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.

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. 


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

    C50.312 Malignant neoplasm of lower-inner quadrant of left female breast

    C50.319 Malignant neoplasm of lower-inner quadrant of unspecified female breast

    C50.321 Malignant neoplasm of lower-inner quadrant of right male breast

    C50.322 Malignant neoplasm of lower-inner quadrant of left male breast

    C50.329 Malignant neoplasm of lower-inner quadrant of unspecified male breast

    C50.411 Malignant neoplasm of upper-outer quadrant of right female breast

    C50.412 Malignant neoplasm of upper-outer quadrant of left female breast

    C50.419 Malignant neoplasm of upper-outer quadrant of unspecified female breast

    C50.421 Malignant neoplasm of upper-outer quadrant of right male breast

    C50.422 Malignant neoplasm of upper-outer quadrant of left male breast

    C50.429 Malignant neoplasm of upper-outer quadrant of unspecified male breast

    C50.511 Malignant neoplasm of lower-outer quadrant of right female breast

    C50.512 Malignant neoplasm of lower-outer quadrant of left female breast

    C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast

    C50.521 Malignant neoplasm of lower-outer quadrant of right male breast

    C50.522 Malignant neoplasm of lower-outer quadrant of left male breast

    C50.529 Malignant neoplasm of lower-outer quadrant of unspecified male breast

    C50.611 Malignant neoplasm of axillary tail of right female breast

    C50.612 Malignant neoplasm of axillary tail of left female breast

    C50.619 Malignant neoplasm of axillary tail of unspecified female breast

    C50.621 Malignant neoplasm of axillary tail of right male breast

    C50.622 Malignant neoplasm of axillary tail of left male breast

    C50.629 Malignant neoplasm of axillary tail of unspecified male breast

    C50.811 Malignant neoplasm of overlapping sites of right female breast
    C50.812 Malignant neoplasm of overlapping sites of left female breast

    C50.819 Malignant neoplasm of overlapping sites of unspecified female breast

    C50.821 Malignant neoplasm of overlapping sites of right male breast

    C50.822 Malignant neoplasm of overlapping sites of left male breast

    C50.829 Malignant neoplasm of overlapping sites of unspecified male breast

    C50.911 Malignant neoplasm of unspecified site of right female breast

    C50.912 Malignant neoplasm of unspecified site of left female breast

    C50.919 Malignant neoplasm of unspecified site of unspecified female breast

    C50.921 Malignant neoplasm of unspecified site of right male breast

    C50.922 Malignant neoplasm of unspecified site of left male breast

    C50.929 Malignant neoplasm of unspecified site of unspecified male breast


    C56.1 Malignant neoplasm of right ovary

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