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Preventive Services Guide


Screening Mammography

A mammogram is an X-ray of the breast. Screening mammograms are routinely administered to detect breast cancer in women who have no apparent symptoms.

Coverage Guidelines and Frequency Limits

Benefits are available for female beneficiaries with no signs or symptoms of breast cancer

  • Aged 35 through 39: one baseline screening
  • Age 40 and older: covered annually
    • At least 11 full months have elapsed since last covered screening (Performed January 2017, begin the count the next month [February 2017], payment for another screening will be eligible in January 2018)
  • Under age 35: no screening mammogram coverage
  • Physician referral/order not required
  • Qualified physician directly associated with facility where mammogram taken must interpret results

Components of screening mammogram include:

  • Radiographic test (mammogram)
  • Interpretation and report
  • Communication of results to patient

Coverage provided by hospital, IDTF, or physician (office or clinic)

  • Cannot be performed by portable X-ray supplier

Mammogram must be provided in FDA-certified radiological facility under MQSA. Claims will deny or reject if:

  • No FDA certification number reported
  • Facility is not certified for the type of mammogram provided
  • Facility’s certification is suspended or revoked
  • There is no FDA certification number on the MQSA file

HCPCS/CPT Coding

These codes are being replaced by the following CPT codes:

  • 77063: screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
    • Use 77063 as an add-on code to 77067 when tomosynthesis is used in addition to 2-D mammography
  • 77067: screening mammography, bilateral (2-view study of each breast), including CAD when performed

Diagnosis Coding

  • Z12.31: Encounter for screening mammogram for malignant neoplasm of breast

Cost Sharing

  • Copayment/coinsurance waived
  • Deductible waived

Reimbursement

Nonparticipating Providers:

  • Nonparticipating reduction applies
  • Limiting charge provision applies

Billing Tips

  • If billing a screening mammogram and a diagnostic mammogram on the same day, use modifier GG to show a screening mammography turned into a diagnostic mammography, bill both screening and diagnostic codes on same claim
    • ICD-10-CM Code: Z12.31 for the screening mammography
    • Diagnostic ICD-10-CM code supporting the reason warranting the diagnostic mammography
  • Cannot bill add-on code without appropriate mammography code
  • Submit rendering NPI as referring physician if self-referred
  • In Item 32 (or electronic equivalent), enter six-digit FDA-approved certification number
  • Use modifier 26 for professional component
    • Interpretations are only to be performed by the physicians who are associated with the certified mammography facility
      • Exceptions:
        • Patient has requested a transfer of the mammography from one facility to another for a second opinion
        • Patient has moved to another part of the country where the next screening mammography will be performed
  • Use modifier 52 for reduced services
    • When services are performed unilaterally

Common Claim Denials

  • Male beneficiary
  • Age requirement not met
  • Covered screening mammogram received within the past year
  • Non FDA-certified mammography provider

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Screening Mammography
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