December 08, 2017

CMS Updates Mammography Guidelines for 2018

As of January 1, 2018, the Centers for Medicare & Medicaid (CMS) will replace the Healthcare Common Procedure Coding System (HCPCS) Level II codes G0202, G0204 and G0206 with the Current Procedural Terminology (CPT®) codes 77065, 77066 and 77067, respectively, to describe both analog and digital mammography exams.

Three Category I codes were created in 2017 to describe digital and analog mammography with computer-aided detection (CAD). These new bundled codes (77065, 77066, 77067) replaced CPT CAD codes 77051 and 77052 and mammography codes 77055, 77056, 77057.

CMS could not operationalize these new CPT codes for 2017 and, therefore, changed the descriptors for the HCPCS Level II G codes G0202, G0204, and G0206 to mirror the CPT codes 77065, 77066 and 77067 for 2017. CMS required G0202, G0204 and G0206 be used in place of the CPT codes for Medicare patients for 2017. For details, see the May/June 2017 ACR Radiology Coding Source article titled Breast Imaging Frequently Asked Questions Updated 2017.

On Aug. 18, CMS released Change Request (CR) 10181 covering mammography HCPCS code replacement and waiver of coinsurance and deductibles for preventive and other services. It noted the replacement of HCPCS codes G0202, G0204 and G0206 with CPT codes 77067, 77066 and 77065. CR 10181 also applies the waiver of deductible and coinsurance to 77067, Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed. Radiology practices should make sure their billing staffs are aware of these changes before their Jan. 1 effective date.

In addition to CR10181, the 2018 National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 9, has been updated, with the following revisions highlighted in red:

CPT code 77063 is an add-on code describing screening digital tomosynthesis for mammography. This procedure requires performance of a screening mammography producing direct digital images. For calendar year 2017 Medicare allowed CPT code 77063 to be reported with HCPCS code G0202, not CPT code 77067. Beginning calendar year 2018 CPT code 77063 may be reported with CPT code 77067. (HCPCS code G0202 was deleted January 1, 2018.)

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), Transmittal 1975 issued 11/9/2017, Change Request 10318, Section 10318.15 Mammograms, regarding National Coverage Determination 220.4, Mammograms, specifies that ICD-10 diagnosis code N63 should no longer be used for reimbursement purposes effective 9/30/17 and that new codes N63.11-N63.14, N63.21-N63.24, N63.31, N63.32, N63.41, and N63.42 would be recognized as of 10/1/17.

The following is a list of valid ICD-10 codes with descriptors effective Oct. 1, 2017:

  • N63.11 Unspecified lump in the right breast, upper outer quadrant
  • N63.12 Unspecified lump in the right breast, upper inner quadrant
  • N63.13 Unspecified lump in the right breast, lower outer quadrant
  • N63.14 Unspecified lump in the right breast, lower inner quadrant
  • N63.21 Unspecified lump in the left breast, upper outer quadrant
  • N63.22 Unspecified lump in the left breast, upper inner quadrant
  • N63.23 Unspecified lump in the left breast, lower outer quadrant
  • N63.24 Unspecified lump in the left breast, lower inner quadrant
  • N63.31 Unspecified lump in axillary tail of the right breast
  • N63.32 Unspecified lump in axillary tail of the left breast
  • N63.41 Unspecified lump in right breast, subareolar
  • N63.42 Unspecified lump in left breast, subareola  

Please contact AJ Hernandez in the department of economics and health policy with your questions on the 2018 revisions of the mammogram CPT and ICD-10-CM codes.