Medicare’s definitions of screening and diagnostic mammography, as noted in the Centers for Medicare and Medicaid’s (CMS’) National Coverage Determination database, and the American College of Radiology’s (ACR’s) definitions, as stated in the ACR Practice Parameter of Screening and Diagnostic Mammography, are provided as a means of differentiating diagnostic from screening mammography procedures. Although Medicare’s definitions are consistent with those from the ACR, the ACR's definitions of screening and diagnostic mammography offer additional insight into what may be included in these procedures. Please go to the CMS and ACR Web site links noted below for detailed comments about these studies.
Medicare Definitions (CMS National Coverage Determination for Mammograms 220.4)
Per the CMS National Coverage Determination, the following definitions for screening and diagnostic mammography are provided:
“A diagnostic mammogram 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.”
“A screening mammogram 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 mammogram has limitations as it must be, at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast.”
Medicare will not pay for a screening mammogram performed on a woman under the age of 35. Medicare will pay for only one screening mammography procedure performed on a woman over age 34 but under age 40. For an asymptomatic woman over age 39, payment may be made for a screening mammography performed after at least 11 months have passed following the month in which the last screening mammography was performed.
As noted in the Medicare Benefit Policy Manual, Chapter 15 ― Covered Medical and Other Health (Section 280.3) “the term ‘screening mammography’ means a radiologic procedure provided to an asymptomatic woman for the purpose of early detection of breast cancer…” Therefore, Medicare does not cover screening mammography for a man.*
Medicare will pay for a diagnostic mammogram when one of the following conditions is met:
- A patient has distinct signs and symptoms for which a mammogram is indicated
- A patient has a history of breast cancer
- 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 [diagnostic] mammogram is appropriate
*Information on the use of modifier KX on claims for transgender patients
ACR Definitions (as defined in the ACR Practice Parameter of Screening and Diagnostic Mammography)
Screening mammography is a radiological examination to detect unsuspected breast cancer in asymptomatic women. Standard views are obtained, and thus the interpreting physician does not need to be present at the facility to monitor the examination when the patient is imaged.
The examination should ordinarily be limited to craniocaudal (CC) and mediolateral oblique (MLO) views of each breast. On occasion, supplementary views may be required to visualize breast tissue completely or optimally, but such views are not ordinarily part of the routine screening examination except for women with implants. Views may be modified to accommodate patient positioning limitations.
Diagnostic mammography is a radiologic examination performed to evaluate patients who have signs and/or symptoms of breast disease, imaging findings of concern, or prior imaging findings requiring specific follow-up. Diagnostic mammography requires direct supervision.1 A diagnostic mammogram may include MLO, CC, and/or additional views to evaluate an area of clinical or radiographic concern. Additional mammographic views might include spot compression, spot compression with magnification, tangential views, or other special views. When selecting a view, the proximity of the area of concern to the image receptor should be considered.
The written or electronic request for a diagnostic mammography examination should provide sufficient information to demonstrate the medical necessity for the examination and allow for its proper performance and interpretation.
As noted in Section II. Indications, B. Diagnostic Mammography, of the ACR Practice Parameter of Screening and Diagnostic Mammography, indications for diagnostic mammography include:
- To assess certain clinical findings that may include a palpable abnormality, persistent focal area of pain or tenderness, bloody or clear nipple discharge, or skin changes.
- A finding detected on screening mammography that requires further imaging evaluation. This could either be a call-back examination following an abnormal screening mammogram, or conversion of a screening mammogram to a diagnostic mammogram when an abnormality is detected at the time of the screening visit.
Short-interval follow-up for probably benign radiographic findings as defined by the ACR Breast Imaging Reporting and Data System (BI-RADS®).
- Asymptomatic patients previously treated for breast cancer may undergo screening or diagnostic mammography at the discretion of the facility.
- Determination that a patient scheduled for screening mammography has a clinical problem, as noted above in section II.B.1. The facility should have a process whereby screening mammography can be converted to diagnostic mammography.
When billing for a Medicare patient who has had a mammogram, one must be cautious to follow the Centers for Medicare and Medicaid Services’ definition. One should consult the local Medicare carrier or Medicare Administrative Contractor to determine how to code for some scenarios. Note that non-Medicare third-party payers should be contacted as they may handle coverage of screening and diagnostic mammograms differently.
1Direct supervision is defined as the physician being present and immediately available to furnish assistance and direction throughout the performance of the procedure. Direct supervision may also be accomplished via telemammography as long as the interpreting physician is immediately available.
Additional views performed to better visualize breast tissue are considered part of the base procedure performed and not reported separately. Although a screening examination should ordinarily be limited to craniocaudal (CC) and mediolateral oblique (MLO) views of each breast, on occasion, supplemental views may be required to visualize breast tissue completely or optimally, but such views are not ordinarily part of the routine screening examination except for women with implants.2
When pathology is suspected, a recommendation for additional imaging studies, diagnostic mammography, or biopsy may be warranted.
2ACR Practice Parameter for the Performance of Screening and Diagnostic Mammography
As of January 1, 2017, three Category I codes were created to describe mammography (both digital and analog) with computer-aided detection (CAD) when performed. These new bundled codes (77065, 77066, 77067) replace CPT CAD codes 77051 and 77052, and mammography codes 77055, 77056, 77057. Note that the Centers for Medicare & Medicaid Services (CMS) could not operationalize these new CPT codes for 2017, and changed the descriptors for the HCPCS Level II G codes G0202, G0204, and G0206 to mirror the CPT codes 77065, 77066, 77067. For 2017, CMS requires G0202, G02024 and G0206 be used in place of the CPT codes for Medicare patients.
It is recommended that providers check with their third party payers for their specific payer requirements.
| Table: Mammography Codes 2017
| Diagnostic mammography, including CAD when performed, unilateral
| Diagnostic mammography, including CAD when performed, bilateral
| Screening mammography, bilateral (2-view study of each breast), including CAD when performed
If a screening mammogram is performed and, after review of the images, pathology is suspected, the interpreting physician is allowed to order additional images. When additional views are obtained, Medicare states that it is appropriate to charge for both a screening mammogram and a diagnostic mammogram whether the studies are performed on the same or different days. If the additional views are done on the same day as the screening mammogram, the diagnostic study should be reported with the GG modifier, which Medicare uses for tracking purposes. This modifier designates the performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day.
In March 2015, CMS responded to an appeal from the ACR regarding a newly implemented National Correct Coding Initiative (NCCI) edit for screening mammography and diagnostic mammography performed on the same patient on the same date of service. CMS elected to retain these NCCI edits. Per CMS, if a provider performs both screening and diagnostic mammography on the same patient on the same date of service, CMS instructions require that a provider report modifier GG with the diagnostic mammography code (77065, 77066, G0204, or G0206). However, because modifier GG is not an NCCI-associated modifier and will not bypass the NCCI edit, providers are instructed to additionally append modifier 59 (Distinct Procedural Service) to the screening mammography (77067 and G0202) to bypass the NCCI edits.
When a patient has a screening mammogram performed on one day and returns on another day for the additional diagnostic mammogram, both the screening mammogram and diagnostic mammogram services should be coded separately. In this scenario, no GG modifier would be required.
See Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services, Section 20.2 ― HCPCS and Diagnosis Codes for Mammography Services
for additional information on the reporting of a screening and diagnostic mammogram performed on the same day.
Yes, it is appropriate to combine the interpretation of a screening and a diagnostic study into one report. According to the ACR Breast Imaging Reporting and Data System (BIRADS®)* frequently asked questions (see Multiple Procedures section):
The facility has the option of issuing either separate reports or one combined report. If two reports are issued, each must contain its own overall final assessment (21 CFR 900.12(c)(1)(iv)). In either case, the facility can report the exam(s) on the same piece of paper.
If the facility decides to issue a single combined report, the facility needs to be aware of the following:
- A combined report must contain a single overall final assessment for the two exams (21 CFR 900.12(c)(1)(iv)).
- The combined report should make it clear that it is combining the results of the screening and diagnostic studies. This is especially important if questions arise about whether the exams were billed correctly.
- Issuing a single combined report with a single final assessment may skew the facility’s medical audit results.
- Though some computerized reporting systems may consider this a single exam (rather than two), the FDA [Food & Drug Administration] would still allow facilities to count both exams toward meeting the continuing experience requirement.
*BI-RADS® was developed by the ACR to standardize mammographic reporting, improve communication, reduce confusion regarding mammographic findings, aid research, and facilitate outcomes monitoring.
When a screening mammography study is ordered and performed on a patient who has only one breast, it is appropriate to report 77067 or G0202 (Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed. Because the CPT code descriptor for 77067 and G0202 state “bilateral,” it would be appropriate to use a 52 modifier (reduced level of service) to designate a screening procedure of only one breast. However, radiology practices should check with their local carrier and other third-party payers regarding the use of the 52 modifier in this situation, because some payers have stated that a 52 modifier is not necessary for reporting a unilateral screening mammogram.
No, it is not appropriate to perform a screening exam on one breast and a diagnostic exam on the other breast. Whenever a diagnostic study is indicated, it is appropriate to do a diagnostic mammogram on one or both breasts as indicated. If a patient presents with a clinical abnormality of the breast, a diagnostic study should be performed. However, it is recommended that radiology practices check with their local carriers and third-party payers as they may have different guidelines.
Yes, it is correct to code a bilateral mammography examination code even though there is no obvious breast tissue because both the side of the remaining breast and the mastectomy side are being imaged. This is analogous to a mammogram of a man, where there is little breast tissue. Depending on the type of mastectomy performed, there may be residual breast tissue left behind, usually in the axillary tail. If there is enough clinical concern to warrant imaging, there is probably clinical concern that a small amount of breast tissue remains. This should, therefore, be billed as a bilateral diagnostic mammogram (77066 or G0204).
According to the ACR Practice Parameter for Performance of Screening and Diagnostic Mammography, the facility and/or interpreting physician can determine whether a woman with augmented breasts (breast implants) is imaged as a screening or a diagnostic patient. The practice parameter notes the following screening mammography indications for a woman with breast augmentation:
6. Woman with breast augmentation
a. Asymptomatic women with breast implants may undergo screening mammography.
b. Facilities must have procedures in place to inquire whether patients have breast implants before a mammogram is performed.
c. If a facility does not provide implant imaging services, it should refer the patient to other facilities that provide such services.
However, the Centers for Medicare and Medicaid Services’ (CMS) payment policy for a diagnostic mammogram does not recognize asymptomatic patients with augmented breasts as diagnostic. Medicare will pay only for a screening mammogram for an asymptomatic woman with breast implants.
Because Medicare denies the necessity of a diagnostic mammogram for an asymptomatic patient with augmented breasts, it is recommended that the physician have the patient sign an advance beneficiary notice form
so that the radiologist may bill the patient for the procedure. If the patient and referring physician decide that a screening mammogram should be performed, then the patient would receive a screening mammogram.
The ACR practice parameters
are an educational tool designed to assist practitioners in providing appropriate radiologic care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician or medical physicist in light of all the circumstances presented. Thus, an approach that differs from the guidelines, standing alone, does not necessarily imply that the approach was below the standard of care.3
3ACR Practice Parameter for the Performance of Screening and Diagnostic Mammography
As noted in the Dec. 8, 1995 Federal Register, the Centers for Medicare and Medicaid Services expanded its definition of diagnostic mammography to include a personal history of biopsy-proven benign breast disease, thereby allowing the attending physician and the patient the opportunity to determine whether a screening mammogram or a diagnostic mammogram is performed.
No, Medicare does not have a specific requirement that a patient with a history of mastectomy must revert back to a screening mammography study after a set number of negative diagnostic studies or after a specified number of years post mastectomy. CMS allows the attending physician and the patient the flexibility to choose whether they want to continue with a diagnostic mammogram or revert back to the screening process.
Yes, in freestanding office and IDTF settings a separate order is required for the addition of a breast ultrasound study following a screening mammography procedure to further evaluate a suspicious finding. The rationale that allows for the performance of a diagnostic mammogram following a screening mammogram without an order from the referring physician does not apply to additional diagnostic testing such as ultrasound or MRI.
The national office of the Health Care Financing Administration (HCFA) notified the ACR that Medicare proposed and adopted the diagnostic mammography exception to the Ordering of Diagnostic Tests Rule (see Medicare Benefit Policy Manual, Chapter 15, Section 80.6
) because Congress made the Food and Drug Administration, rather than HCFA, responsible for the conditions under which mammograms are covered. In addition, the screening mammography benefit contains no requirement for a physician’s order. Thus, a beneficiary could receive the screening mammogram on a walk-in basis, with no treating physician to order the subsequent diagnostic procedure. Note that the Ordering of Diagnostic Test Rule does not apply in the hospital setting (see Thomas Scully letter to American Hospital Association, Response #1).
No code is available to describe computer-aided detection (CAD) performed in conjunction with breast ultrasound. CAD performed in conjunction with breast sonography is reported with the unlisted CPT code 76999 (Unlisted ultrasound procedure (e.g., diagnostic, interventional)) to describe the CAD analysis and CPT code 76641 (Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete) or 76642 (Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited) to describe the breast ultrasound study.
Yes, it is appropriate to report the Category III code 0159T to describe CAD performed in conjunction with a breast MRI study even though pharmacokinetic analysis is not performed. Code 0159T should be used to describe any type of CAD (Confirma, In-Vivo, CAD Sciences, etc.) performed in conjunction with an MRI of the breast. The phrase “including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis” in the descriptor clarifies that this code includes this type of analysis if performed, and it should not be coded separately. Code 0159T is an add-on code to a breast MRI procedure and, therefore, must be reported in addition to one of the breast MRI without and/or with contrast codes (77058 unilateral, 77059 bilateral). This coding recommendation is clarified in the AMA/ACR Clinical Examples in Radiology (Volume 3, Issue 2, Spring 2007).
Note that because the CAD software automatically performs three-dimensional (3D) imaging, the CAD procedure code was valued to include 3D imaging, and codes 76376 and 76377 should not be reported in addition to 0159T.
The ACR presented a code proposal at the June 2017 CPT Editorial Panel meeting that requested MRI breast codes bundle in the performance of CAD when performed. If approved, these new codes will be available for use in 2019.
No, an order is not required for the use of CAD performed in conjunction with breast imaging procedures, such as mammography, MRI, and ultrasound. When CAD is performed, a statement such as “CAD software was used” should be inserted into the report.1
As noted in the Winter 2007 issue of the AMA/ACR Clinical Examples in Radiology, an order is not required for the performance of CAD because CAD is covered under the Ordering of Diagnostic Tests design exemption (Section 80.6.4).
The Centers for Medicare and Medicaid Services informed the ACR that the Ordering of Diagnostic Tests Rule allows for performance of CAD in conjunction with mammography without a written order from the referring (treating) physician. Because there is no medical necessity prerequisite for the use of CAD with mammography procedures, and if all aspects of CAD are performed in conjunction with mammography, the radiologist may determine whether or not CAD should be performed. The use of CAD is covered under the Radiologist Exception as noted in Medicare Transmittal #1725:
15021 (E)(1) Test Design [see Internet Only Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services 80.6.2.]
Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media).
1AMA/ACR Clinical Examples in Radiology Volume 1, Issue 4; Fall 2005, p. 13.
No, it is not appropriate to separately code for the review of prior mammographic images when they are not available for comparison at the time of interpretation of the current images. The comparison of prior images, which may be an important part of diagnostic mammography, is considered part of the mammography procedure. Radiology practices should work to ensure images are available for comparison at the time of the current mammography interpretation.
Digital subtraction should not be reported in addition to the code for a breast MRI with contrast study or any other MRI study. Digital subtraction is a scanner-performed function that generates another set of images. This is similar to another pulse sequence in MRI or another set of windows in computed tomography. Therefore, the digital subtraction would be inherent in the breast MRI procedure. It is not a post-processing function on a separate workstation.
In the past, the ACR maintained that an order for 2D and 3D reconstruction imaging was not necessary because this was covered under the Ordering of Diagnostic Tests Rule test design exception (Chapter 15, Medicare Benefit Policy Manual, Section 80.6.4
). However, based on the exponential rise in the use of 3D rendering codes 76376 (not requiring image post-processing on an independent workstation) and 76377 (requiring image post-processing on an independent workstation) and in the number of practice investigations evolving out of overutilization (routine use), the ACR strongly encourages radiology practices to obtain an order from the referring physician in the non-hospital setting. In the hospital setting, radiologists may generate their own order, but they are strongly encouraged to justify medical necessity for the use of 3D rendering in a separate dictation.
Codes 19281-19288 were specifically created to describe breast marker placement in the absence of performing a biopsy. To report bilateral image-guided placement of localization devices see codes 19281, 19283, 19285, or 19287 for the initial lesion localized, depending on the modality used for imaging guidance. The contra-lateral and each additional breast image-guided localization device placement(s) is reported with codes 19282, 19284, 19286, and 19288. For example, when a breast localization device is placed using stereotactic guidance, code 19283 is reported for the first lesion and add-on code 19284 for each additional lesion. If the patient subsequently goes on to surgical excision the same day, it is appropriate to report the radiograph of the surgical specimen using code 76098, Radiological examination, surgical specimen.
Metallic pellets, radioactive seeds, RFID devices or any other localization devices used during a breast biopsy or breast localization are all included in codes 19081-19086 and 19281-19288. Note that these codes are used once per lesion localized, regardless of the number of localization devices placed in or around the lesion (i.e., if a mammographic-guided needle localization is performed using two radioactive seeds to designate the margins prior to surgical excision, code 19281 is still only reported one time).
Yes, it is appropriate to report radiographs of a surgical specimen (76098) performed after a breast localization (19281-19288). However, radiographs of the specimen samples obtained at the time of biopsies are included in the breast biopsy codes (19081-19086).
The choice of the appropriate breast biopsy CPT code is based on the technique used, that is, whether the study was performed percutaneously (19100, 19081-19086) or open (19101), and whether or not it was performed with image-guidance (19081-19086) or without image guidance (19100).
CPT code 19100 describes a percutaneous needle core biopsy when imaging guidance is not required, for example, a biopsy of a palpable breast lesion. Per AMA’s CPT 2017 introductory notes: codes 19081-19086 are used to describe image-guided breast biopsies, including the placement of localization devices when performed. The image-guided placement of localization devices without image-guided biopsy are reported with 19281-19288.When more than one biopsy or localization device placement is performed using the same imaging modality, use an add-on code whether the additional service(s) is on the same or contra-lateral breast. If additional biopsies or localization device placements are performed using different imaging modalities, report another primary code for each additional biopsy or localization device placement performed using a different image guidance modality. When more than one breast biopsy is performed using the same imaging modality, use an add-on code whether the additional service(s) is on the same or contra-lateral breast...To report bilateral image-guided breast biopsies, report 19081, 19083, or 19085 for the initial biopsy. The contra-lateral and each additional breast image guided biopsy are then reported with code 19082, 19084 or 19086.
Please note that if multiple breast biopsies are performed, the biopsy procedure code is submitted per lesion and NOT per sample.
It is only appropriate to bill for a consultation or other evaluation and management (E&M) service when the service is provided and documented according to established E&M guidelines. For breast interventional procedures, a brief review of history and physical exam and obtaining informed consent is not a separately reportable E&M service. The Relative (Value Unit) Update Committee (RUC) database clearly indicates that such discussion of findings with the patient is part of the valued work (and thus reporting this separately with an E&M code is unbundling).
A copy of the 1995 and 1997 E&M published guidelines are available on the Centers for Medicare and Medicaid Services web site. It is up to the provider to choose which published guidelines to follow. However, it is recommended that for auditing purposes a radiology practice use one set of guidelines, that is, either 1995 or 1997.
Yes, a signed informed consent form must be obtained prior to the performance of a breast cyst aspiration or breast core biopsy. Obtaining informed consent from the patient or appropriate designee as defined by local regulations for these breast procedures is no different from obtaining informed consent for any other invasive or interventional procedure.
No, if multiple samples are taken from the same lesion, the biopsy code should be reported only once. However, when separate lesions are sampled during the same session, it is appropriate to report the biopsy codes multiple times based on the number of separate lesions sampled.
Breast tomosynthesis is a digital tomographic technique performed using multiple low-dose X-ray exposures. The resulting image data is reconstructed using standard computer algorithms to produce a series of sequential, stacked slices through the breast. This type of tomographic imaging enables the physician to view the breast(s) as thin, discrete image slices on a computer workstation. The addition of digital breast tomosynthesis (DBT) to conventional mammography has been shown to be more sensitive and specific for breast cancer detection.
The Current Procedural Terminology (CPT®) Editorial Panel created three Category I codes to describe unilateral diagnostic (77061), bilateral diagnostic (77062), and screening (77063) breast tomosynthesis procedures, which became available for use as of January 1, 2015. However, CMS recognized 77063 only for screening DBT as an add-on code, but did not recognize the stand-alone diagnostic DBT codes 77061 and 77062. In place of using 77061 and 77062, CMS created the HCPCS Level II add-on code G0279 to describe diagnostic DBT, whether unilateral or bilateral.
CMS requires use of HCPCS Level II G codes in 2017. Other payers may require use of CPT Category I codes.
It is anticipated that CMS will recognize the new codes in 2018. Check the ACR Radiology Coding Source for future changes to this coding recommendation.
ACR published in the Nov-Dec 2014
ACR Radiology Coding Source Q&A advice that a planar mammogram is a planar mammogram, regardless if that planar mammogram was directly acquired FFDM data or synthesized from the DBT data set. Planar mammograms are coded as 77065, 77066, 77067, or G0202, G0204, G0206.
The Centers for Medicare and Medicaid Services provided guidance to ACR stating that G0279 should be billed with G0204 or G0206, even if a diagnostic planar mammogram was NOT performed. Codes G0279 and G0206 should be reported to describe a unilateral diagnostic digital breast tomosynthesis (DBT), regardless if a planar unilateral diagnostic mammogram was performed. Codes G0279 and G0204 should be reported to describe a bilateral diagnostic DBT, regardless if a planar bilateral diagnostic mammogram was performed.
There is nothing in the regulations that requires supervision by a radiologist for mammography procedures. The October 31, 1997, the Healthcare Financing Administration [now known as the Centers for Medicare and Medicaid Services (CMS)] final rule clarifying the appropriate level of physician supervision for diagnostic tests payable under the Medicare Physician Fee Schedule does not apply to mammography procedures. Mammography is covered under the Food and Drug Administration’s Mammography Quality Standards Act (MQSA) guidelines, which also do not address the issue of supervision. However, the ACR Practice Parameter of Screening and Diagnostic Mammography recommends direct supervision of diagnostic procedures. Direct supervision is defined as the physician being present and immediately available to furnish assistance and direction throughout the performance of the procedure. Direct supervision may also be accomplished via telemammography as long as the interpreting physician is immediately available.
Code Z12.31 (Encounter for screening mammogram for malignant neoplasm of breast) should be reported as the primary diagnosis code when screening mammography is performed even when the outcome of the study renders a positive finding.
As noted in Diagnostic Coding and Reporting Guidelines for Outpatient Services of the ICD-10-CM Official Guidelines for Coding and Reporting:
- A screening code may be a first-listed code if the reason for the visit is specifically the screening exam.
- Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.
Also refer to Chapter 18, Medicare Claims Processing Manual, Section 20.2 - HCPCS and Diagnosis Codes for Mammography Services for additional information on the reporting of ICD-10 codes for mammography procedures.
The referring physician does not need to specify in an order if a complete or limited breast ultrasound is required. The type of ultrasound performed may be determined by the radiologist under the Ordering of Diagnostic Test Rule exemption, similar to the decision to perform a CT with or without contrast. For example, if the order is for breast ultrasound, the radiologist may determine if it should be a complete or limited ultrasound based on the medical necessity. However, if the referring physician specifies that a complete or limited ultrasound should be performed, the radiologist should speak with the referring physician if the radiologist disagrees with the type of study requested.
As noted above, the determination of whether a complete or limited study is performed falls under the Ordering of Diagnostic Tests Rule exemption, i.e., “Unless specified in the order, set the protocol for a given diagnostic, interventional, or therapeutic procedure ordered (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media)” (see Section 80.6, Chapter 15, Pub. 100-02 of the internet-only Medicare Benefit Policy Manual).
Per the CPT® 2017 codebook, Professional Edition, p. 456, code 76641 represents a complete ultrasound examination of the breast. Code 76641 consists of an ultrasound examination of all four quadrants of the breast and the retro-areolar region. It also includes ultrasound examination of the axilla, if performed.
Code 76642 consists of a focused ultrasound examination of the breast limited to the assessment of one or more, but not all of, the elements listed in code 76641. It also includes ultrasound examination of the axilla, if performed. If only the axilla is scanned, it should be coded as a limited extremity ultrasound,76882
Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final written report, is not separately reportable.
The breast ultrasound codes are unilateral procedures. When the same type of breast ultrasound study is performed on both breasts, it is appropriate to report the code twice – once with an RT modifier and once with an LT modifier to designate a bilateral procedure was performed. For example, a complete breast ultrasound of both the right breast and left breast would be reported as 76641-RT and 76641-LT. As modifiers are payer specific, check with your third party payers to determine how you should report these procedures.
No, Medicare does not pay for a breast ultrasound when performed as a screening study, as Medicare pays for screening studies only when they are Congressionally mandated. Medicare will pay for a diagnostic breast ultrasound if medically indicated.
If breast ultrasound is performed as a screening study, a Medicare patient would be responsible for payment. Non-covered services (i.e., services excluded by law or under a non-benefit category) do not require that a waiver (Advance Beneficiary Notice) be signed, and the patient is responsible for payment. Click here for more information on Medicare’s Advance Beneficiary Notice.
For most purposes, women whose breasts are classified as heterogeneously dense or extremely dense are considered to have dense breasts. Some states have enacted breast density notification laws that require women to be informed when a mammogram indicates that she has dense breasts. Other supplementary imaging tests may help find breast cancers that cannot be seen in dense breasts during a mammography exam, which include breast tomosynthesis, breast ultrasound, and breast MRI.1
When a physician’s opinion or advice regarding a specific film is requested by another physician, and on examination of the film the consulting physician provides his or her opinion or advice to the requesting physician in a written report, the specific procedure code with a 26 modifier (professional component only) should be used. Some Medicare carriers require that modifier “77” also be used to indicate that a basic procedure or service performed by another physician had to be repeated. Please check with your local Medicare carrier for their guidelines. Other carriers and third-party payers may have different guidelines and may recommend the use of CPT code 76140 (Consultation on X-ray exam made elsewhere, written report).
As noted in the American Medical Association’s Principles of CPT Coding, if a patient comes to an office for a new or established patient visit and brings the physician his or her medical records, including X-rays, the review or reread of the X-rays would be considered part of the face-to-face evaluation and management service provided to the patient and would not be reported separately.
For more information on second opinions, please reference Dr. Richard Duszak’s article “Another Unpaid Second Opinion,” JACR, Volume 2, Issue 9, Pages 793-794 (September 2005).
The Centers for Medicare & Medicaid Services has instructed providers to use the institution’s NPI number for self-referred mammograms for all claims submitted on or after May 23, 2008. Please reference the CMS Change Request 6023 MedLearn Matters educational article which states:
- Institutional providers submitting claims for self-referred mammography services will duplicate the institution’s own NPI in the attending physician NPI field on their claims; and
- Suppliers submitting claims for self-referred mammography services will duplicate the supplier’s own NPI in the attending/referring physician NPI field on their claims.
Both the ACR and the Society of Nuclear Medicine and Molecular Imaging recommend that CPT code 78800 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area) be reported for a breast scintigraphy study of either one or both breasts. Although it is recognized that there is more work in imaging both breasts, the original intent of the multiple areas CPT code (78801) refers to multiple sites in the body versus both sides of the same part of the body. Just as imaging of the chest for other nuclear medicine procedures is considered one single limited area, both breasts are considered a single limited area as well.
Reference the ACR’s Breast Imaging Resources page for additional information.