Detect Breast Cancer Early On with Mammograms
Mammography for breast cancer screening sees many changes to coding guidelines and reporting in 2017 and 2018.
October is Breast Cancer Awareness Month, making it an ideal time to review coding and coverage guidelines for mammography. These guidelines have undergone major changes in the past year, with further changes expected in 2018.
2017 Introduced New Breast Imaging Codes
The 2017 CPT® codebook deleted breast imaging codes 77051-77057 and replaced them with three new codes:
77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral
77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed
The primary difference between the old and new codes is that the new codes include computer-assisted detection (CAD), when performed. The American College of Radiology describes CAD as, “a computer-based process designed to analyze mammographic images for suspicious areas; in effect, it is a ‘second pair of eyes’ for the radiologist.” Studies suggest that CAD aids in early detection of breast cancer, but also may increase the incidence of “false positive” results.
Codes 77065 and 77066 describe diagnostic mammography. This means a specific indication (sign, symptom, or diagnosis) prompts the provider to order the service. The codes describe unilateral (77065, single breast) and bilateral (77066, both breasts) imaging.
Code 77067 describes a screening mammography, which by definition is bilateral and includes two views of each breast. Screening exams do not require the patient to have a specific complaint or indication of disease, but are provided as a preventive measure to detect and contain any possible disease before it results in signs, symptoms, or other ill health. Breast cancer typically is treated successfully, if found early.
Medicare Specifies Unique Coding Guidelines
Medicare did not adopt the new CPT® codes, described above, for 2017. Instead, the Centers for Medicare & Medicaid Services (CMS) continues to require the use of dedicated G codes to describe mammography services for Medicare beneficiaries:
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 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral
A keen eye may notice the descriptors for these codes match exactly those of CPT® codes 77067, 77065, and 77066. CMS has previously stated that it intends to adopt the CPT® codes, in place of the G codes listed above, beginning in 2018. At the time this article was published, the change was not confirmed. Keep an eye on Healthcare Business Monthly or AAPC’s online Knowledge Center for updates, as they are available.
How to Report Tomography
Breast tomosynthesis is an advanced form mammography that uses low-dose X-rays and computer reconstructions to create 3-D images of the breasts. It’s also called 3-D mammography or digital breast tomosynthesis (DBT). Breast tomosynthesis is described using CPT® +77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure). This is an add-on code, which per CPT® instructions may be reported only with 77067 (screening mammography).
CMS will accept 77063 with screening mammography in 2018, but also offers a unique G code, G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206), that may be reported in addition to diagnostic mammography services G0204 or G0206. CMS guidelines specify, “When breast tomosynthesis is furnished, practitioners should report one of G0202, G0204, or G0206 and one of G0279 or 77063. For purposes of billing digital breast tomosynthesis, the appropriate, accompanying 2D image(s) may either be acquired or synthesized.”
Example 1: If a Medicare patient undergoes screening mammogram and screening tomosynthesis, report G0202 and 77063.
Example 2: A patient with commercial insurance undergoes screening mammogram and screening tomosynthesis. This payer follows CPT® guidelines. Report 77067 and 77063.
Coverage Rules Matter
Coverage requirements of screening mammography for Medicare patients are:
Women 40 and older are eligible for a screening mammogram every 12 months. Medicare also covers one baseline mammogram for women between 35-39.
How often is it covered?
Once every 12 months
How does CMS define “high risk” for breast cancer?
The individual had breast cancer in the past.
The individual has a family history of breast cancer.
The individual had her first baby later than age 30, or has never had a baby.
Coverage rules for screening services can vary considerably from payer to payer. Check with your individual payers for screening mammography coverage, as well as acceptable diagnoses to report diagnostic mammography.