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 2024, begin the count the next month [February 2024], payment for another screening will be eligible in January 2025)
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

CPT Coding

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

ICD-10 Coding

Z12.31

Note: Report dual diagnosis codes depicting specific quadrants instead of unspecified quadrants, if appropriate.

Note: Additional ICD-10 codes may apply. See the CMS ICD-10 webpage for individual Change Requests and the specific ICD-10-CM codes Medicare covers for this service.

Cost Sharing

Copayment/coinsurance waived
Deductible waived

Reimbursement

MPFS: Fee Schedule Lookup

Nonparticipating Providers

Nonparticipating reduction applies
Limiting charge provision applies

Billing Tips

When screening turns into diagnostic mammography (same day, same beneficiary)
- Add GG Modifier to the diagnostic code
- Add 59 or XU modifier to the screening code
- Bill both the screening and diagnostic codes on the same claim
- Use a screening ICD-10-CM code 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

Additional Services

Prolonged Preventive Services

Clock symbol next to CPT codes 77063 and 77067 in the MLN Educational Tool^® Medicare Preventive Services indicates these codes can be billed with a prolonged preventive services add-on code.
Used when the service time exceeds the typical service time for the specific service
Must be a valid clinical reason included in the documentation to support the medical necessity of the additional time

Common Claim Denials

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