What differentiates a diagnostic from a screening mammography procedure?
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 more indepth information about these studies.
Medicare Definitions
“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.
ACCEPTED Medicare Codes for Diagnostic Mammograms:
| Procedure: | ICD 10 Codes: |
| Screening Mammogram History of Breast Cancer Abnormal Mammogram Induration of Breast Nipple Discharge Retraction of Nipple Other Breast Symptoms Mastodynia Breast Implants Family History of Breast Cancer History of Dimpling Gynecomastia | Z12.31 Z85.3 R92.8 N64.51 N64.52 N64.53 N64.59 N64.4 Z79.82 Z80. Z87.2 N62.0 |
Mammogram CPT codes 77055, 77056
CPT 77055 – Mammography; unilateral CPT 77056 – Mammography; bilateral
These codes are used for diagnostic mammography procedures, which are x-ray examinations of the breast used to detect and diagnose breast disease in women experiencing symptoms such as a lump, pain, or nipple discharge, as well as for those who have had an abnormal screening mammogram.
Insurance Guidelines
Both CPT 77055 and 77056 are typically covered under insurance when medically necessary, such as in patients showing symptoms of breast disease or changes noted in previous mammograms. Coverage may include:
- Annual screening for women over age 40.
- Diagnostic follow-up after an abnormal screening mammogram.
- Evaluation of breast changes if a woman is symptomatic.
For Medicare, these services are covered under specific conditions, which require that:
- The patient shows distinct signs and symptoms for which a mammogram is indicated.
- There is a history of breast cancer or a significant judgment by a physician deeming the mammogram necessary based on the patient’s medical history and other factors.
CPT Code Guidelines and Usage
When billing, these codes replace older mammography codes and should be used for claims:
- CPT 77055 replaces 76090 (unilateral diagnostic mammography).
- CPT 77056 replaces 76091 (bilateral diagnostic mammography).
Providers should be aware of the technical (TC) and professional (PC) components, which may be billed separately depending on the service setting.
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