Today marks the final day of October, the nationally recognized month for Breast Cancer Awareness. Of course, the whole point of the campaign is not to simply bring out our pink ribbons for a few weeks and then stow them away again until next year. Instead — we all collectively use this opportunity to remind ourselves and one another that we must continue to support efforts toward finding the cure and promote an awareness of the available screening and prevention tools that can lead to early diagnosis and treatment.
We would like to take a quick moment to remind physicians and patients to pursue screening mammograms following best practice guidelines. Much legislation is in place to ensure that insurance carriers comply in covering these screenings in accordance with the nationally recognized medical standards of organizations including the American Cancer Society (ACS). Commercial insurance coverage varies by state, and by plan. We recommend checking out the ACS website for a launching point on determining coverage guidelines for carriers in your state: https://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-paying-for-br-ca-screening.
As a Federal program, the Medicare coverage guidelines for screening mammography are universal. Consider the points below as helpful reminders regarding these coverage rules (based upon the Medicare Learning Network August 2012 publication on Screening and Diagnostic Mammography):
- Medicare does not require a physician’s prescription or referral for screening mammography.
- Medicare waives the coinsurance or copayment and Part B deductible for screening mammography based on the USPSTF 2002 recommendation on breast cancer screening.
- Medicare covers diagnostic mammography as often as medically necessary [diagnostic mammography is to check for breast cancer after the discovery of a lump or other sign/symptom of breast cancer. Screening mammography is used for early detection when there are no signs or symptoms of the disease present.]
- Medicare covers one screening for women aged 35-39 years (called a “baseline” screening), and then covers an annual screening for women aged 40 and older.
- ICD-9 Codes & CPT/HCPCS Codes to Report for Screening
ICD-9-CM Diagnosis Code
|V76.11||Special screening for malignant neoplasms, screening mammogram for high-risk patient|
|V76.12||Special screening for malignant neoplasms, other screening mammogram|
|CPT/HCPCS Code||Code Descriptor|
|77052||Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure)(Use 77052 in conjunction with 77057)|
|77057||Screening mammography, bilateral (2-view film study of each breast)(Use 77057 in conjunction with 77052 for computer-aided detection applied to a screening mammogram)(For electrical impedance breast scan, use 76499)|
|G0202||Screening mammography, producing direct digital image, bilateral, all views|
|77051||Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure)(Use 77051 in conjunction with 77055 or 77056)|
|77055||Mammography; unilateral(Use 77055 in conjunction with 77051 for computer-aided detection applied to a diagnostic mammogram)|
|77056||Mammography; bilateral(Use 77056 in conjunction with 77051 for computer-aided detection applied to a diagnostic mammogram)|
|G0204||Diagnostic mammography, producing direct digital image, bilateral, all views|
|G0206||Diagnostic mammography, producing direct digital image, unilateral, all views|