When billing for mammograms, documentation must include the purpose and the result of the procedure. Two major purposes of mammogram are diagnostic and screening. It can also be used mammography to guide other procedures.

Determine the purpose of the procedure; i.e. whether it was performed for diagnosis or screening. 

Diagnostic: There are two codes for diagnostic mammography. Bill CPT® codes 77055 and 77056 depending on whether the procedure was perform on one or both sides.

 

Screening: Screening Mammography is done on asymptomatic woman for early detection of breast cancer. You should CPT® code 77057 for screening mammography. 

 

To perform screening mammography, there need not be signs, symptoms, or any history of breast disease. The screening exam will be covered even without a prescription or referral from another doctor. Medicare specifies age and frequency for patients for whom screening mammography is covered. However, when the radiologist performs a diagnostic mammogram; there should be a physician’s order, some signs and symptoms, or a personal history for which the test is warranted.

Note: You should not use number of views as a criterion to distinguish screening vs. diagnostic. Screening mammography usually is has two views craniocaudal (CC) and mediolateral oblique (MLO). However, the number of views should not be considered a criteria to differentiate a screening mammogram from a diagnostic one because more than two views may be required for screening mammogram in certain situations. Typically  diagnostic mammogram has latero-medial (LM) or medio-lateral (ML) views along with the CC and MLO views.

If both screening as well as diagnostic mammograms are performed on the same day, report both and append modifier GG to the diagnostic mammogram code. If the patient visits the radiologist for a routine screening mammogram, and an abnormality is identified, they might perform unilateral or bilateral diagnostic mammogram. In such cases, Medicare will cover both the exams. 

 

Age is an important criterion:  Medicare will pay for screening mammograms under certain condition.

 

·  Screening mammography is not covered for patients under age of 35 years.

·  Age 35-39: One screening mammography is covered.

·  Over age 39: One Screening mammography is covered every year.

 

Screening mammography is typically performed on both breasts and therefore, the description includes “2-view film study of each breast”. In case a screening exam is done on a patient who had a mastectomy, screening is done unilaterally. In such case, use code 77055 (Mammography; unilateral), because, the criterion for personal history is satisfied. Also, ICD-9-CM codes V10.3 (Personal history of malignant neoplasm of breast)should be reported to justify. You can check with the payer in case they have any other specific rule for such scenarios.

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