There is a significant change in coding for Digital Breast Tomosynthesis (DBT) in 2015. Three new procedure codes have been introduced in the 2015 CPT manual to describe the physician work and practice expense involved in breast tomosynthesis.
The Centers for Medicare & Medicaid Services (CMS) also created an additional new G code (HCPCS Level II code) for Tomosynthesis, effective from January 1, 2015. To ensure accurate coding and appropriate reimbursement, it is very important to understand when and how to appropriately assign these codes.
New Codes for DBT
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- 77061: Digital breast tomosynthesis; unilateral
- 77062: Digital breast tomosynthesis; bilateral
- 77063: Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure)
- G0279: Diagnostic digital breast tomosynthesis, unilateral or bilateral
Appropriate Use of New Codes
77063
The new procedure code 77063 designated for screening services is an add-on code and will only be paid when furnished in conjunction with a 2D digital mammography. As CMS instructs in MLN Matters® article MM8874-Revised, 77063 must be reported with G0202 (screening mammography, producing direct digital image, bilateral, all views, 2D imaging only) from January 1, 2015. The CPT manual indicates that 77063 should not be reported with either regular 3D rendering codes 76376/76377, or the regular diagnostic mammography codes 77055/77056. Payment for 77063 will be made only when the screening is medically necessary and reported with any of the following diagnosis codes.
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- V76.11: Screening mammogram for high-risk patient
- V76.12: Other screening mammogram
- Z12.31: Encounter for screening mammogram for malignant neoplasm of breast (when ICD-10 is effective)
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Other Codes
The remaining three tomosynthesis codes 77061, 77062 and G0279 are used to report services performed in conjunction with diagnostic mammograms. G0279 is an add-on code and can be reported only in conjunction with 2D mammography, while the other two codes can be reported as stand-alone services. When Billing Medicare for DBT performed in conjunction with a diagnostic mammogram, G0279 should be reported with either G0204 (Diagnostic mammography, producing direct 2D digital image, bilateral, all views) or G0206 (Diagnostic mammography, producing direct 2D digital image, unilateral, all views). This includes examination of either one or both the breasts. When billing non-Medicare payers, 77061 (unilateral) or 77062 (bilateral) should be used to report tomosynthesis.
There are no co-pays or deductibles associated with the new screening DBT codes, including add-on code 77063. G0279 relates to a diagnostic procedure and does not follow the same policies established for the screening studies. You should append modifier GG (Performance and payment of a screening mammography and diagnostic mammography on the same patient, same day) to indicate that the test changed from a screening test to a diagnostic test. Only then will the payers will pay for both tests.
Though Medicare provides coverage for screening tomosynthesis, most payers consider this service to be investigational and will not provide separate payment. So it is very important to understand the policy of top payers regarding tomosynthesis reimbursement. Consider partnering with a Professional Medical Billing and Coding Company to ease the medical coding burden, enhance accuracy and obtain maximum reimbursement.
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