Reporting Mammograms for Medicare Patients
Coding these preventive procedures depends on the payer.
For 2017, the American Medical Association (AMA) deleted CPT® 77051, 77052, 77055, 77056, and 77057, and introduced three replacement codes to report mammography:
77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral
77066 … bilateral
77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed
The reason for the change is that the industry standard for mammograms now bundles computer-assisted detection (CAD) with mammograms. The new codes bring the description of service in line with current practice.
The descriptors for these new codes mirror, exactly, the HCPCS Level II codes for reporting mammography services:
G0202 Screening mammography bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed
G0204 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral
G0206 … unilateral
Codes G0202-G0206 are required when reporting mammography to Medicare payers. Codes 77065-77067 have not replaced G0202-G0206 for Medicare billing.
Get to the Root of the Problem
On Jan. 4, the Centers for Medicare & Medicaid Services (CMS) published an update to Change Request (CR) 9861 (originally released on Nov. 16, 2016) and its accompanying spreadsheets for the National Coverage Determinations (NCD) affected by the CR. Unexpectedly, CMS added a note in the Revision History for NCD 220.4 Mammograms, stating that it would not recognize the 2017 CPT® codes for mammograms. CMS explained, “This is the result of being unable to properly process claims using CPT codes 77065, 77066, and 77067 for 2017.” CMS said that it intends to recognize the 2017 CPT® codes for mammograms in 2018.
Screening Mammography Codes
On Jan. 1, 2015, CMS announced it would recognize CPT® 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure), per MLN Matters® number: MM8874. Per NCD 220.4, updated Jan. 4, Medicare continues to recognize 77063 in 2017 for screening digital tomosynthesis performed at the same time as G0202 for Medicare patients.
Diagnostic Mammography Codes
Per NCD 220.4, updated Jan. 4, CMS recognizes G0204 or G0206 with +G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206). Because G0279 is an add-on code, it must be reported with either G0204 or G0206. CMS instructs, “For the purpose of billing digital breast tomosynthesis the appropriate accompanying 2D image(s) may either be acquired or synthesized.” This applies to both G0279 and 77063.
CGS Medicare administrative contractor directs:
HCPCS code G0279 has been assigned a bilateral indicator “2” in the Medicare Physician Fee Schedule Database (MPFSDB). A “2” indicator means special payment adjustment for bilateral does not apply. Because of this, bilateral modifiers (e.g., CPT modifier 50, HCPCS modifiers RT/LT) are not to be included and the units field should indicate a quantity of “1.”
Professional Mammography Services
For 2017 professional (practitioner’s) claims, report mammography services using the G codes (G0202, G0204, G0206, G0279) or 77063. Be sure the service ordered and performed matches the description of the code. It is easy to confuse screening versus diagnostic and the accompanying tomosynthesis codes.
The CMS spreadsheet updated and released on Jan. 4 for CR9861 is confusing; it still contains the expired CPT® codes, but you may not use them for dates of service past Dec. 31, 2016.
Let’s review some examples to see how you should code a mammogram service for a Medicare beneficiary patient versus patient with commercial insurance:
A screening mammogram without tomosynthesis is coded G0202. If the patient also has screening tomosynthesis, add 77063. Be sure to check the NCD for the covered diagnoses and allowable frequency.
A diagnostic mammogram is coded as either G0204 (diagnostic bilateral) or G0206 (diagnostic unilateral). If tomosynthesis is ordered, also report G0279 to either G0204 or G0206, as appropriate.
Payers other than Medicare will likely use the new CPT® codes, but check with them to be sure. If a payer is using the CPT® codes, a screening mammogram is coded as 77067. If tomosynthesis is ordered, also report 77063.
For commercial diagnostic mammograms, code either 77065 or 77066, depending on the order. If tomosynthesis is provided, also report G0279.
Codes 77065-77067 have not replaced G0202-G0206 for Medicare billing.
Q – If we are only doing a screening mammogram, do we have to report G0202 plus 77063?
A – No, only report a tomosynthesis if it was ordered and performed. Use 77063 in conjunction with G0202, or G0279 in conjunction with G0204 or G0206.
Q – Is this only for Medicare patients?
A – This coding guidance only applies to Medicare patients for dates of service in 2017. Check with all other payers to be sure they are recognizing the new CPT® codes for mammograms.
Q – Are we supposed to report the G codes for the professional service?
A – Yes, for Medicare patients only, for 2017 dates of service, report the G codes for professional services. This likely will change in 2018.
Q – If we do not do the computer-aided detection (CAD) portion, what codes are we supposed to use?
A – For Medicare patients, for 2017 dates of service, use the G codes regardless if CAD is used.
Barbara Aubry, RN, CPC, CPMA, CHCQM, FABQAURP, is a senior regulatory analyst for 3M Health Information Systems (HIS). As a member of the 3M HIS team that creates and manages medical necessity and other coding data, she works directly with the ICD-10 code translation and assignment for NCD medical necessity policies. Aubry’s clinical background includes experience in hospital case management and utilization review. Her core focus is regulatory compliance and auditing, and she is member of the Upper Saddle River, N.J., local chapter.
CMS Transmittal 1755, CR 9861:
CMS, Frequently Asked Questions for Mammography Services:
CGS, May 11, 2015: Add=On HCPCS Code G0279 for Diagnostic Digital Breast Tomosynthesis:
NCD 220.4 Mammograms