Screening Mammography

Medicare Reimbursement Guidelines

  • No payment will be made for a screening mammography performed on a woman under the age of 35.

  • Payments will be made for only the first screening mammography performed on a woman over the age of 35 but under the age of 40.

  • For an asymptomatic woman over age 40, 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.

  • Must be billed as CPT code 77067.

Commercial Reimbursement Guidelines

The Affordable Care Act (ACA) requires commercial health plans to provide a single covered screening for women between the age of 40

  • No payment will be made for a screening mammography performed on a woman under the age of 40 or over the age of 74.

  • For an asymptomatic woman over age 40, 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.

  • Must be billed as CPT code 77067. Use modifier 33.

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.

Diagnostic Mammography

  • A patient has distinct signs and symptoms for which a mammogram is indicated.

  • A patient has a history of breast cancer.

  • A patient is asymptomatic but on the basis of the patient's history and other factors the physician considers significant, the physician's judgement is that a mammogram is appropriate.

  • Must be billed as CPT code 77066 or 77065.

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