- In the U.S.A., medical procedures are billed using both an ICD (International Classification of Disease) code and a CPT (Current Procedural Terminology) code.
- Use those codes to check with your insurance company to learn if a specific test should be covered and what your out-of-pocket costs (copay, deductible, or coinsurance) may be.
- Coverage varies by state and specific insurance plan.
Insurance Billing Codes by Breast Imaging Test
ICD CODE: For women with dense breasts, an appropriate ICD-10 code is R92.3(which is “Mammographic density found on imaging of breast”). Note: other diagnosis codes may also apply based on medical history.
CPT CODES Terms you may hear: one breast = unilateral, both breasts = bilateral
Bạn đang xem: What are insurance billing codes for additional breast screening tests?
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TestCPT CodeDetails 2D Mammogram (screening)77067 (both breasts, 2-views of each)Code also includes computer-aided detection (CAD) when performed. The Affordable Care Act requires insurers to cover annual screening mammography beginning at age 40, without any out-of-pocket costs. For younger women at high risk, screening mammography typically requires a prescription from a physician and may be subject to out-of-pocket costs. 2D Mammogram (diagnostic)77065 (one breast) 77066 (both breasts)Codes also include computer-aided detection (CAD) when performed. Diagnostic mammography is typically subject to out-of-pocket costs. A diagnostic mammogram is monitored by the radiologist and should only be performed for patients with an appropriate indication such as a lump, nipple discharge, other symptom, or to further evaluate or follow-up abnormalities previously noted on breast imaging. Women with a personal history of cancer can have their routine annual mammogram performed as a diagnostic or a screening examination. 3D Mammogram/tomosynthesis (screening)77067 (2D both breasts) + 77063 (3D both breasts )Most major insurers cover screening tomosynthesis; additionally, many states now require coverage. Out-of-pocket costs are possible. 3D Mammogram/tomosynthesis (diagnostic)77065 (2D one breast) + 77061 (3D one breast) 77066 (2D both breasts) + 77062 (3D both breasts) G0279 – 3D (one or both breasts) if Medicare is primary insuranceOut-of-pocket costs usual. A diagnostic 3D mammogram is monitored by the radiologist and should only be performed for patients with an appropriate indication such as a lump, nipple discharge, other symptom, or to further evaluate or follow-up abnormalities previously noted on breast imaging. Women with a personal history of cancer can have their routine annual 3D mammogram performed as a diagnostic or a screening examination. Contrast-enhanced Mammogram (CEM)Currently no CPT code Most CEM is done as part of research studies at this time. In centers offering clinical CEM, billing is often under CPT code 77065 (one breast) or 77066 (both breasts). Out-of-pocket costs usual. Some centers will also bill for the contrast and the contrast injection. Ultrasound76641 (per breast)“Complete” breast ultrasound is used for screening and will be billed for each breast, usually at half the rate for the second breast. Out-of-pocket costs usual in most states. A “limited” breast ultrasound, 76642, is used to evaluate abnormalities or particular areas of concern. Molecular Breast Imaging, MBI78800Out-of-pocket costs usual. Magnetic Resonance Imaging, MRI (with contrast)77048 (one breast) 77049 (both breasts)May require pre-authorization from your health provider. Out-of-pocket costs usual in most states. Abbreviated MRI (with contrast)Currently no CPT code unique to abbreviated MRI. The American College of Radiology endorses use of the modifier, “-52” (limited) exam, in combination with full protocol MRI CPT code 77049 (click HERE for more details, page 12). Many centers will bill directly to the patient (range $200-$600). © DenseBreast-info.org
Updated Nov 3, 2021. DenseBreast-info.org endeavors to provide up-to-date insurance codes; however, codes can change. These codes may not be the most recent version. No representations or warranties of any kind are made, express or implied, about the completeness, accuracy or reliability of this information provided. A patient should always check with their specific insurance provider.
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Learn More:
- 5 Facts Every Woman Should Know
- Video Series: Let’s Talk About Dense Breasts
- Patient Risk Checklist (print)
- Patient Questions and Answers
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