Seeking the correct code to bill for a unilateral diagnostic mammogram? CPT code 77065 is the right choice. But do you really know its billing requirements?
Approximately 43 million mammography procedures are performed annually in the U.S. However, only 10% of patients are recalled for further evaluation, that is, a diagnostic mammogram.
So, while this procedure may be routine for you as a radiologist, we understand how tricky its coding can be. The main reason? Screening and diagnostic mammography codes are quite similar. That’s why we are taking a closer look at the 77065 CPT code today.
CPT Code 77065 – Description
So, what exactly does this code specify? As hinted in the intro, CPT code 77065 refers to a unilateral diagnostic procedure. To be more specific, this code reports a detailed examination of a single breast with computer-aided detection (CAD).
The primary purpose? To investigate abnormalities identified during a screening mammogram or a new symptom, such as a lump or nipple discharge. In short, diagnostic mammography is more comprehensive than a screening breast examination.
During this procedure, a radiologist takes multiple X-ray images of the breast while it is compressed. He then uses specialized software to analyze these detailed images, examining the area of concern.
Scenarios Where CPT Code 77065 is Applicable
Need some real-world examples to understand CPT code 77065 better? Here are three specific scenarios:
Breast Mammography to Investigate a Lump
While 60 to 80% of breast lumps are non-cancerous, they should always be investigated for early detection. Some lumps, discovered through self-exam or any method, can be malignant. So, let’s come up with a similar scenario for this example.
Suppose a 34-year-old woman with a family history of breast cancer often performs a self-examination. During one of these, she feels a lump in her right breast near the armpit. She immediately consults a primary care physician who orders a mammogram after examination.
A radiologist performs the imaging test and analyzes the images via software. He then sends the report to the physician and bills the diagnostic mammography procedure involving CAD with CPT code 77065.
Diagnostic Mammography for the Suspicious Calcifications
Abnormalities detected on the screening mammography procedures often require a follow-up procedure. Therefore, let’s consider a 45-year-old woman who arrives at a radiology department following a screening mammography.
The key reason? The radiologist found a suspicious abnormality, let’s say certain patterns of calcifications (bits of calcium), in the left breast. Hence, the patient’s physician called her back for a follow-up mammogram of that breast.
The radiologist performs the procedure with CAD detection to analyze the calcifications better. He then uses CPT code 77065 to report this unilateral diagnostic mammography.
Diagnostic Mammography to Analyze Nipple Discharge & Localized Pain
Breast cancer, the second most common cancer among women in the U.S., accounts for 30% of all new cases annually. The most common symptoms? Lumps, nipple discharge, breast swelling, and dimpling skin.
So, for this example, assume a 41-year-old woman arrives at a hospital outpatient department with two complaints: localized pain and nipple discharge from her left breast. The healthcare provider examines her condition, takes her history, and orders a diagnostic mammogram.
A radiologist performs the test, taking several X-ray images of the patient’s left breast and analyzing them in detail via software. He then uses CPT code 77065 to bill for the procedure.
Applicable Modifiers for CPT Code 77065
To provide extra details about this diagnostic mammography, you can use the following modifiers with CPT code 77065:
Modifier 26
Were the mammographs interpreted by the physician? Append modifier 26 to CPT code 77065 to bill for the professional component.
Modifier TC
Did you only perform breast mammography without interpretation? For example, the test was performed at an imaging center, and the facility wants to bill for its equipment and technologist support.
In this case, you can use modifier TC with CPT code 77065 to indicate the technical part of the diagnostic procedure.
Modifier LT
Was mammography performed on the left breast? Communicate this information by applying modifier LT to the 77065 CPT code.
Modifier RT
On the other hand, use modifier RT with the 77065 CPT code if the procedure was performed on the right breast.
Modifier GG
Did you perform a diagnostic mammography on the same patient and on the same day as the screening mammography? Append modifier GG with CPT code 77065 to differentiate the procedures.
CPT Code 77065 – Billing & Reimbursement Guidelines
Now, here comes the most important part! To avoid billing issues and outright denials, follow these billing and reimbursement guidelines for CPT code 77065:
Use CPT Code 77065 for Diagnostic Mammography
Special emphasis on diagnostic! The 77065 CPT code only covers a diagnostic mammography on one of the breasts with computer-aided detection. Keep in mind that a test without CAD is often considered a screening mammography.
Therefore, you cannot use it to bill for a screening procedure. We are highlighting this point again and again because radiologists and radiology coders often make this mistake.
Bill for a Unilateral Procedure
Unilateral is another important keyword! Avoid using the 77065 CPT code for bilateral diagnostic mammography. There is a different code for that (CPT code 77066).
Justify Medical Necessity
Payers cannot distinguish between screening and diagnostic procedures unless you provide complete documentation. Therefore, clarify why you have performed a mammography. You must document the following details in the patient’s medical record as well as in the referral order:
- Written referral
- Patient’s symptoms (pain, nipple discharge) or relevant abnormal screening results
- Appropriate ICD-10 codes
- Description of the test
- Interpretation and results
Append Appropriate Modifiers
You must always specify laterality, that is, the exact breast on which you performed the mammography. To do that, append either the LT or RT modifier with CPT code 77065. For communicating additional details, you can also use other modifiers like 26, TC, GG, or 59.
Verify Payer-Specific Requirements
Medicare and commercial payers may have different coverage rules for diagnostic mammography. Therefore, always verify their requirements before filing a claim for the 77065 CPT code.
Summary
Do you now understand all the billing requirements for CPT code 77065? We hope that you do, since it is an important code. You can use it to report a mammogram with CAD, but only if it is diagnostic and performed on one breast. Our blog has explained this code in quite detail, even providing you with three detailed examples, so you know how to apply it correctly.
Simply follow our instructions to file clean claims. But if you want to be paid on time, it is best to bring a professional into the mix. An expert with reliable radiology billing services can help you stay compliant and ahead of your competition.
