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:
*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:
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.
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 or 77066,). 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) 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:
*BI-RADS® was developed by the ACR to standardize mammographic reporting, improve communication, reduce confusion regarding mammographic findings, aid research, and facilitate outcomes monitoring.
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
Prior to January 1, 2019, breast MRI with CAD was reported with Codes 77058, 77059, and 0159T, these codes have been deleted and replaced with new codes 77046-77049. The ACR presented a code proposal at the June 2017 CPT Editorial Panel meeting that requested the MRI breast codes bundle in the performance of CAD, when performed. The new CPT codes were approved for use beginning January 1, 2019.
|CPT Description||CPT Codes|
|MRI, breast, without contrast; unilateral||77046|
|MRI, breast, without contrast; bilateral||77047|
|MRI, breast, without and with contrast, including CAD, when performed; unilateral||77048|
|MRI, breast, without and with contrast, including CAD, when performed; bilateral||77049
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.
For more information on the Ordering of Diagnostic Test Rule, reference Further Clarification on the Ordering of Diagnostic Tests Rule in the July- Aug 2003 ACR Radiology Coding Source ACR Radiology Coding Source July-August 2003
Percutaneous breast biopsy procedures are reported with CPT codes 19081-19086 and 19100 based on whether the procedure performed is with or without imaging guidance. When percutaneous placement of a localization device is performed without the performance a breast biopsy, see codes 19281-19288.
Table 1 below provides a summary of the breast biopsy and placement of breast localization device codes. For detailed guidelines on the reporting of these codes, please reference the AMA’s CPT 2019 introductory notes, which state the following:
Table 1: Reporting of Breast Biopsy and Placement of Location Devices
|BREAST NEEDLE BIOPSY||CPT|
|Breast biopsy w/o imaging guidance, percutaneous||19100|
|Stereotactic guidance, 1st lesion||19081|
|Stereotactic guidance, each additional lesion||19082|
|Ultrasound guidance, 1st lesion||19083|
|Ultrasound guidance, each additional lesion||19084|
|Magnetic resonance guidance, 1st lesion||19085|
|Magnetic resonance guidance, each additional lesion||19086|
|Tomosynthesis guidance w/o stereotactic||19499|
Breast biopsy includes: imaging, placement of localization device(s), and imaging of biopsy specimen, when performed
|BREAST LOCALIZATION DEVICE(S) W/O BREAST BIOPSY||CPT|
|Mammographic guidance, 1st lesion
|Mammographic guidance, each additional lesion||19282|
|Stereotactic guidance, 1st lesion||19283|
|Stereotactic guidance, each additional lesion||19284|
|Ultrasound guidance, 1st lesion||19285|
|Ultrasound guidance, each additional lesion||19286|
|Magnetic resonance guidance, 1st lesion||19287|
|Magnetic resonance guidance, each additional lesion||19288|
|Surgical specimen radiography||76098|
Effective for dates of service on or after January 1, 2019, CPT codes 10004-10012, and 10021 are used to describe fine needle aspiration biopsies of the breast. CPT code 10022 has been deleted and is no longer available for use.
The following table lists the breast FNA biopsy codes differentiated by “with” or “without” imaging guidance and the type of guidance provided.
|FINE NEEDLE ASPIRATION BIOPSY||CPT|
|FNA Bx w/o Imaging, first lesion||10021|
|FNA Bx w/o Imaging, ea addt'l||10004|
|FNA Bx w/ Ultrasound, first lesion||10005|
|FNA Bx w/ Ultrasound, ea addt'l||10006|
|FNA Bx w/Fluoro, first lesion||10007|
|FNA Bx w/Fluoro, ea addt'l||10008|
|FNA Bx w/CT, first lesion||10009|
|FNA Bx w/CT, ea addt'l||10010|
|FNA Bx w/MR||10011|
|FNA Bx w/MR, ea addt'l||10012|
Do not report 10004, 10021 in conjunction with 10005-10012 for the same lesion.
The AMA’s CPT 2019 codebook guidelines, General Guidelines Fine Needle Aspiration (FNA) Biopsy, differentiate between FNA and needle core biopsies as follows:
A fine needle aspiration (FNA) biopsy is performed when material is aspirated with a fine needle and the cells are examined cytologically. A core needle biopsy is typically performed with a larger bore needle to obtain a core sample of tissue for histopathologic evaluation. FNA biopsy procedures are performed with or without imaging guidance.
In addition, the CPT 2019 codebook lists the following important notes:
When more than one FNA biopsy is performed on separate lesions at the same session, same day, same imaging modality, use the appropriate imaging modality add-on code for the second and subsequent lesion(s).
When more than one FNA biopsy is performed on separate lesions, same session, same day, using different imaging modalities, report the corresponding primary code with modifier 59 for each additional imaging modality and corresponding add-on codes for subsequent lesions sampled.
This instruction applies regardless of whether the lesions are ipsilateral or contralateral to each other, and/or whether they are in the same or different organs/structures.
When FNA biopsy and core needle biopsy both are performed on the same lesion, same session, same day using the same type of imaging guidance, do not separately report the imaging guidance for the core needle biopsy. When FNA biopsy is performed on one lesion and core needle biopsy is performed on a separate lesion, same session, same day using the same type of imaging guidance, both the core needle biopsy and the imaging guidance for the core needle biopsy may be reported separately with modifier 59. When FNA biopsy is performed on one lesion and core needle biopsy is performed on a separate lesion, same session, same day using different types of imaging guidance, both the core needle biopsy and the imaging guidance for the core needle biopsy may be reported with modifier 59.
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.
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 sen¬sitive and specific for breast cancer detection.
The Current Procedural Terminology (CPT®) Editorial Panel created three Cat¬egory I codes to describe unilat¬eral 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.
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 Servicesf. A screening code may be a first-listed code if the reason for the visit is specifically the screening exam.
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).
For more information on the Ordering of Diagnostic Test Rule, reference Further Clarification on the Ordering of Diagnostic Tests Rule in the July- Aug 2003 ACR Radiology Coding Source
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 mandated by Congress. 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. For more information view 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 MLN Matters® Article which states:
The appropriate CPT code to report an ultrasound examination of the breast is 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).
Whenever a screening examination is performed, the screening ICD-10 [diagnosis] code is the first-listed, regardless of the findings or any procedure that may be performed as a result of the findings. Therefore, an ultrasound screening examination of the breast should be reported with ICD-10 code Z12.39 (Encounter for other screening for malignant neoplasm of breast). It is recommended that a secondary diagnosis be reported (e.g., R92.2, Inconclusive mammogram – dense breasts NOS) to communicate to the payer that the study was performed for a high risk patient.
For Medicare patients, the Centers for Medicare & Medicaid Services gives direction on the coding of unspecified quadrants in the National Correct Coding Determination (NCD) for Mammograms, which states:
Contractors shall add ICD-10 diagnosis codes N63.10, N63.20 to covered diagnosis list effective October 1, 2018. Note: Dual diagnosis codes depicting specific quadrants can be reported instead of unspecified quadrants if found more appropriate by provider.
For more information click here.
The AMA/ACR Clinical Examples in Radiology Fall 2016 issue provides guidance on the reporting of both a stereotactic and tomosynthesis imaging-guided core breast biopsy as follows:
When a breast biopsy is performed using both stereotactic and tomosynthesis imaging guidance, it is appropriate to use CPT code 19081, Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when per¬formed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance.
If a combination stereotactic–tomosynthesis-guided biopsy is performed using a separate piece of equipment (such as a prone table) and the patient is moved to another unit for a post-procedure mammogram, it is appropriate to report the post-procedure mammogram separately. If the combination stereotactic–tomosyn¬thesis-guided biopsy is performed using a standard digital breast tomosynthesis mammography unit on which the post-procedure mammogram is also obtained, it is not appropriate to report the post-procedure mammogram separately.”