Screening Mammography
A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician’s interpretation of the results of the procedure. A screening mammography has limitations as it must be, at a minimum, a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast.
Diagnostic Mammography
A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, a personal history of breast cancer, or a personal history of biopsy-proven benign disease, and includes a physician’s interpretation of the results of the procedure.
Indications and Limitations of Coverage
Screening Mammography (77057, G0202)
The following guidelines apply to screening mammograms:
- Under age 35 - Payment may not be made for a screening mammography;
- Over age 35, but under age 40 - Payment may be made for only one screening mammography;
- Over age 39 - For an asymptomatic woman, payment may be made after at least 11 months have passed following the month in which the last screening mammography was performed.
The 11-month period is calculated by counting beginning with the month after the month in which a previous screening mammography was performed.
Unlike diagnostic mammographies, there do not need to be signs, symptoms, or history of breast disease in order for the exam to be covered. Screening mammograms should be reported with diagnosis code V76.11 or V76.12.
A doctor’s prescription or referral is not necessary for the procedure to be covered. Payment may be made for a screening mammography furnished to a woman at her direct request, and based on a woman’s age and statutory frequency parameter.
Mammography facilities that perform screening mammograms are NOT to 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 unless the patient has moved to another part of the country where the next screening mammography will be performed. Interpretations are to be performed ONLY by physicians who are associated with the certified mammography facility.
Diagnostic Mammography (77055, 77056, G0204 or G0206)
A radiological mammogram 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; or,
- 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.
A diagnostic mammography must ordered by a doctor of medicine or osteopathy.
Screening Mammography/Diagnostic Mammography – Same Day
When a screening mammography changes to a diagnostic mammography on the same date of service, both services are eligible for reimbursement. Modifier -GG is required when a diagnostic mammogram is performed on the same day as a screening mammogram. If the modifier is missing, the claim will be denied because the required modifier was not submitted. The claim can be resubmitted for consideration with the appropriate modifier.
Computer-Aided Detection (CAD) (77051 or 77052)
Computer-aided detection (CAD), “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” can be billed in conjunction with primary screening mammograms using code 77052 for screening mammograms or using code 77051 for diagnostic mammograms.
The medical necessity criteria outlined above also applies to the CAD (77051 or 77052) when reported in conjunction with either a screening or diagnostic mammogram.
Mammography related CAD equipment does not require FDA certification. Mammography utilizes a direct x-ray of the breast. By contrast, the CAD process uses laser beam to scan the mammography film from a film (analog) mammography, converts it into digital data for the computer, and analyzes the video display for areas suspicious for cancer. The CAD process used with digital mammography analyzes the data from the mammography on a video display for suspicious areas. The patient is not required to be present for the CAD process.
Reasons for Noncoverage
Services are not eligible when performed in a facility that is not FDA-certified.
Computer-aided detection reported independent of the primary procedure, whether screening or diagnostic, will be denied.
Use code 77051 with codes 77055, 77056, G0204, or G0206 to report computer-aided detection applied to a diagnostic mammogram.
Use code 77052 with codes 77057 or G0202 to report computer-aided detection applied to a screening mammogram.
Use codes 77055 (unilateral) and 77056 (bilateral) to report a diagnostic mammogram.
Use code 77057 to report a bilateral screening mammogram.
Use code G0202 to report a screening mammogram, producing direct digital images.
Use codes G0204 (bilateral) or G0206 (unilateral) to report diagnostic mammograms, producing direct digital images.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
CMS Online Manual Pub. 100-02, Chapter 1, Section 50
CMS Online Manual Pub. 100-02, Chapter 15, Sections 80, 280.3
CMS Online Manual Pub. 100-03, Section 220.4
CMS Online Manual Pub. 100-04, Chapter 18, Sections 20.1, 20.1.3, 20.2.1, 20.2.1.1, 20.7
The following diagnosis codes apply to Screening Mammograms (77052, 77057, and G0202)