CPT Code 77067: Screening Mammography Billing Guide
CPT code 77067 describes a screening mammography study performed on each breast with two views of each breast and computer-aided detection (CAD) if performed. This code describes screening studies and does not pertain to the evaluation of breast symptoms. Routine screening is typically reported with ICD-10-CM code Z12.31. If a tomosynthesis study is part of a screening mammography study, 77063 is also reported. Diagnostic mammography studies are reported with CPT codes 77065 or 77066 depending on the examination.
For the billing staff the challenging part is making the clinical indication, radiology report, and claim agree. A screening label on the scheduling system does not clarify a documented symptom, base code, or global codes. This document provides support and justification for a mammography claim.
Mammography CPT code 77067: service description
The standard examination includes craniocaudal and mediolateral oblique views of each breast. The radiology report should state the screening purpose, describe the examination and include the finding and conclusion of the interpreting physician.
The bilateral description is important. Consider a complete bilateral screening as a single service. Two breasts and their standard views do not create separate units of CPT code 77067.
CAD is included when used
The performance of computer-aided detection (CAD) in a mammography service captures its inclusion. The inclusion of CAD does not make it mandatory. A screening examination can support the code in the absence of CAD if the service otherwise meets the description.
CAD assistance should not be added to increase reimbursement for the same examination. The report can identify the software assistance used without treating that assistance as a separate payable mammogram.
An extra image should also be distinguished from another examination. An additional view required to complete the documented examination does not, in and of itself, create a separate service which can be reported. The clinical situation, in combination with the complete imaging record, determines the proper code assignment.
77067 vs 77066 vs 77065: choose the examination performed
The main distinction is screening versus diagnostic intent. Laterality then separates the diagnostic codes.
| Code | Examination | Breast coverage | Coding distinction |
|---|---|---|---|
| 77067 | Screening mammography | Bilateral | Screening of an asymptomatic patient |
| 77066 | Diagnostic mammography | Bilateral | Diagnostic evaluation involving both breasts |
| 77065 | Diagnostic mammography | Unilateral | Diagnostic evaluation involving one breast |
For CPT code 77067, an appointment labeled “screening” isn’t enough. If the patient reports a lump or nipple discharge, route that information to the clinical team so the examination reflects the documented concern.
Likewise, a diagnostic mammogram isn’t defined by the number of images alone. The report must support the diagnostic purpose and the breast or breasts evaluated.
Findings do not invalidate a legitimate screening exam
A screening can identify an abnormality. This does not mean the screening was incorrectly coded.
Judge whether the documentation supports a screening exam or a distinct diagnostic exam, based on the applicable conversion rules. Do not assign a diagnostic code just because a screening report states further evaluation is recommended.
If the indication and the report are in conflict, obtain clarification. Correcting the diagnosis to evade an edit does not correct the documentation error and leaves a higher risk that the record will be selected for audit.
Match CPT code 77067 with ICD-10 to justify the need for screening
Z12.31 indicates screening mammograms. For a routine screening, Z12.31 is usually the first listing. For this code to be assigned, the service line must be pointed to the service that supports the assignment of Z12.31.
This is a line-level check. It is possible for a claim to list Z12.31 and for the service line to point to a different code, thus justifying the absence of the code, but not the need for a line-level review.
Risk factors and personal history require context
Numerous personal and family history codes impact the risk for developing cancer. They do not justify the assignment of the code or support the need for the evaluation.
There are many risk factors and family history codes that can be researched including Z80.3 for family history of breast malignancy, Z15.01 for genetic susceptibility to breast malignancy and Z85.3 for personal history of breast malignancy.
For CPT code 77067, differentiate screening from disease surveillance. A request for an evaluation of an active concern should be supported by documentation.
Address an abnormal result without creating a diagnosis
Per the ICD-10-CM screening guidelines, if the condition that is discovered as a result of screening is appropriately documented, it can be reported as an additional diagnosis. Classification instructions, exclusions and reason for the code still apply.
For a diagnostic workup, describe the symptom or finding that was used to order the imaging and/or the documented diagnosis at the correct level of specificity. Do not reach to explain an image as being malignant. Not every imaging finding in the breast is interchangeable.
CPT code 77067 and 77063: screening tomosynthesis
CPT code 77067 is assigned for screening mammography and CPT code 77063 is assigned for screening DBT. 77063 reports bilateral screening DBT and is an add-on code that is to be reported with the base code of the screening mammography procedure.
When both screening DBT and mammography are performed and documented, the base code for screening mammography (00310) and 77063 are reported, and diagnostic service 77067 is supported by the diagnosis. Check that the add-on code was actually reported, as in some interfaces, the add-on may be reported disconnected from the base code.
Always keep screening and diagnostic DBT separate
G0279 describes qualifying diagnostic DBT done in conjunction with diagnostic mammography. Other payers may accept diagnostic DBT codes 77061 and 77062. Check to see what is accepted. Do not substitute 77063 for diagnostic imaging.
Breast ultrasound is a separate service and is described by codes 76641 and 76642, respectively, for complete and limited bilateral exams. Report breast ultrasound only when it is medically necessary and the documented requirements are met. A screening mammogram doesn’t always warrant coverage for breast ultrasound.
Just because multiple imaging procedures are performed on a patient, it does not mean that there are unrelated diagnoses. Each line requires an appropriate supported indication, and the documented finding may relate to more than one service.
CPT code 77067 modifiers: components, reduced services and conversions
Modifiers must reflect the service the billing entity actually performed and is authorized to report. Modifiers cannot create a professional interpretation or technical component, or separate examination that the medical record does not support. Reliable Medical Billing and Coding Services help ensure that each modifier appropriately reflects the work and payer requirements.
Modifiers 26 and TC: Professional versus technical work
Modifier 26 identifies professional interpretation and reporting. Modifier TC identifies the technical component of an appropriate professional-format claim. In global billing, both components are included in the applicable billing arrangement.
An independent radiology group interpreting an imaging center’s study may report CPT code 77067 with modifier 26. A qualifying supplier reporting only the technical work may use modifier TC. An entity reporting both the professional and technical work, may use the global code without either component modifiers.
Assuming the equipment ownership decides the billing question is not always the case. The component billed (i.e. interpreting) and providing the service must agree with the documentation.
Hospital institutional billing often has its own set of billing rules. A hospital’s technical service should not be automatically assumed to be another supplier’s professional-format TC service. The same service may affect payment reconciliation.
Modifier 52: Unilateral Screening
There is no CPT code specific to screening one breast. The ACR states that to report unilateral screening, one may report 77067 with modifier 52. Variation among payers should be taken into consideration.
The report should describe the breast examined and state the reason for reduced service. Check reduced service reporting for add-on codes if screening tomosynthesis is also performed unilaterally.
Replacing an unsupported unilateral screening mammography with a diagnostic mammogram just because the screening code describes a bilateral service is incorrect. For CPT code 77067, the clinical reason is still part of the decision.
GG, 59 and XU: qualifying screening to diagnostic conversion
GG indicates the qualifying performance of screening and diagnostic mammography and is reported on the diagnostic mammography line. The presence of GG indicates the patient is not high risk.
For the Medicare conversion pathway, NCCI states modifier 59 or XU on the screening line if both services were performed and the full criteria are met.
The diagnostic report should state the reason for the additional service. A screening mammogram should not be billed as a diagnostic mammogram just because there is a modifier on the screening code. A modifier does not turn one service into two.
Modifiers 33, 50, 76 and 77
Modifier 33 is usually not needed for CPT 77067, as the code describes preventive screening. Noridian states that modifier 33 should not be added to codes that describe preventive services.
Modifier 50 is not appropriate for a bilateral screening mammogram as scope for bilaterality is already described in 77067.
Modifiers 76 and 77 should not be added for the purpose of justifying a diagnostic radiological service. NCCI states that images needed to complete a service are considered part of the total service provided.
Documentation checklist for CPT code 77067
CPT code 77067 is defined as breast imaging for screening by digital breast tomosynthesis (DBT). The documentation checklist is organized in two parts: (1) Clinical evidence and (2) supporting information. The radiologist’s report describes the service performed. Eligibility and enrollment checks support and address different things.
A helpful review checklist includes:
- Patient’s ID and clinically appropriate screening indication
- Patient’s symptoms relevant to the exam
- Breast(s) imaged, and the imaging technique
- Reported views and findings
- Breast composition
- Final assessment and impression
- Use of Computer Aided Detection (CAD) in the study, if performed, and without a separate charge
- Evidence documenting screening DBT, when performed and reported
- Reason for limited examination
- Follow up recommendations
- Information on the ordering/referring health care provider, if required by the payer
- Benefit eligibility, component ownership and performing facility check
- Verification of ownership and performing facility check, when needed, by screening payers
MQSA compliance is a different consideration. The requirements to certify the performing facility and to report and document mammography, including density, are by the Food and Drug Administration (FDA). An incorrect diagnosis cannot repair an invalid performing facility certification record.
For CPT code 77067, assign responsibility for resolving discrepancies. The indication is clarified by the clinical staff. The service and diagnosis are validated by the coding staff. Failing records are reconciled by enrollment staff. A “billing issue” label is non-informative.
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CPT code 77067 and Medicare Screening Mammography
Medicare covers screening mammography for beneficiaries who meet requirements of age and frequency.
Frequency eligibility should be validated using the Medicare benefit response and applicable CMS guidance. A scheduling label or patient recollection is not an acceptable substitute for an eligibility check.
The coverage determination should reflect whether the screening mammography is covered, what rules of the benefit were determined, and who needs to resolve an exception to those rules. Frequency issues should prompt a benefit review rather than an assumption that the coverage is for a diagnostic mammogram.
Coverage Guidance and Clinical Recommendations are Distinct
Payment Eligibility for a particular payer benefit determines what is covered. Clinical recommendations are provided to help guide the standard of care. They should be assessed and determined independently. The final clinical decision remains with the treating and interpreting professionals.
For commercial payers and Medicaid, verify the specific plan rather than assume it is the same as Medicare. Screenings, diagnostic breast imaging, and breast imaging-related supplemental studies, and diagnostic breast ultrasound should be assessed as separate benefits.
Also verify imaging and interpreting services are in-network. A facility’s participation in a network does not always mean that the professional component is as well.
Retain Useful Payer Verification
When assessing benefit eligibility, be sure to evaluate the specific service combination that is being requested. Asking “is a mammogram covered” may resolve the eligibility of the DBT add-on or supplemental imaging, for example.
Retain plan identification, benefit responses, and any authorization. Express any unresolved questions rather than assume an open-ended benefit determination response means coverage.
A good handoff includes which procedures have been verified, which entities have been billed, and which plan provisions need clarification, as opposed to simply including a screenshot of the service in question.
Explain Patient Responsibility Accurately
For a covered Medicare screening mammogram, the beneficiary pays nothing when the provider accepts assignment. Diagnostic mammograms, however, are subject to the applicable diagnostic benefit and cost-sharing rules.
For commercial plans, coverage and cost-sharing rules are plan-specific and may vary. Avoid assuring the patient that all breast imaging would be fully covered and carry no patient responsibility.
For CPT code 77067, if it is determined that the service would not be covered, follow the requirements for a Notice of Financial Assistance and Relation to Coverage, and not use a Financial Consent form.
For CPT code 77067, verify reimbursement
Each payer has different reimbursement amounts for CPT code 77067 based on multiple factors including the locale, payment methodology and policy, practice expense, and malpractice. RVUs describe relative resources, and are not dollar amounts.
Use a reproducible reimbursement check
Verify the applicable CMS Fee Schedule, Localities, and indicators for payment, and compare that with the processed claim for Medicare.
With the contracted allowed amount and terms, a payer determines what it owes your organization. Collections from an imaging center or the billed charge from another provider do not set the payer’s obligation.
Keep the supporting entry or contract reference with the underpayment request. This allows other staff to reconstruct the calculation instead of interpreting an undefined amount on a spreadsheet.
Hospital mammography also has special Medicare payment instructions. Location of the hospital alone does not assume an ordinary OPPS payment; apply the mammography rules for the provider and claim type.
Separate a low payment from a coding error
Payment discrepancies should be reviewed against coding, reported services, reductions, locality and payer contract before being classified as underpayments. Verify that the claim was fully adjudicated and compare equivalent services as professional-only and global payments are not interchangeable. Through the use of Medical Coding Services, each payment should be reviewed to include the code and modifier, if any, allowed amount and the payer rule being invoked, to correlate to a request for correction.
Mammography billing scenarios
The scenarios listed are examples and not audited client cases or instructions to code without record review.
Scenario 1: Screening Mammography (with a Screening DBT)
A healthy patient is documented to have had a bilateral screening mammogram, and a bilateral screening DBT. One entity supplies and reports the complete service.
This review supports CPT code 77067 and add-on code 77063 with the code for screening line Z12.31. Documented risk factors may be warranted for further reporting. The absence of a component modifier should not be interpreted as a base code + add-on code combination.
The easiest control is to reconcile the documentation of DBT (Documents in Both Time) provided by radiology against both claim lines. A correct base claim can conceal a missing add-on claim.
Scenario 2: Documented symptom on screening appointment
The patient’s booking states ‘screening’ and the clinical record documents a concern that is palpable. The appropriate diagnostic examination is performed by the radiologist.
Coding adheres to the documented diagnostic service and laterality; coding 77065 or 77066 is supported. The diagnosis is derived from the documented reason or an established finding. CPT code 77067 should not be assigned against the clinical documentation to support the appointment type.
Scenario 3: Qualifying conversion claim
Record shows a completed screening examination and a separate diagnostic examination meeting Medicare’s conversion criteria.
A possible example of how to lay out a claim is to use 77067-59 or 77067-XU for the screening component and 77065-GG for the diagnostic component. This example provides only conversion modifiers; component modifiers and the mechanics of how to format the claim will require a separate review.
A supported indication is necessary for a diagnostic component. Copying the screening diagnosis across every component of the claim may mask the difference the claim is intended to show.
Scenario 4: screening of one breast
A patient who previously underwent a unilateral mastectomy is documented to have received a screening mammogram of the remaining breast. There is no documentation to support a diagnostic component of the mammogram and it is assumed to be routine screening.
Evaluate 77067-52 in conjunction with the payer’s guidelines and evaluate 77063-52 if a unilateral diagnostic breast tomosynthesis was performed. It may be assumed the base-code modifier applies to the add-on code in both cases; however, a review of the reduced service handling is necessary.
Common CPT code 77067 denials and practical fixes
Read the adjustment group, claim adjustment reason code and remark codes together. A diagnosis-related denial doesn’t prove that every claim needs Z12.31 substituted, and a payment reduction doesn’t automatically establish a billing error.
| Claim problem | Evidence to review | Appropriate response |
|---|---|---|
| Screening and diagnostic mismatch | Clinical indication, report and diagnosis pointers | Clarify the record; correct only an actual reporting error |
| Frequency denial | Verified benefit eligibility and screening utilization | Resolve the coverage calculation or challenge an incorrect determination |
| Unpaired 77063 | Base procedure, claim linkage and DBT documentation | Correct the missing or mismatched base/add-on reporting |
| Duplicate component billing | Claims from the interpreting group and technical supplier | Establish ownership of each component and correct overlapping charges |
| Conversion edit | Distinct examinations and conversion-modifier placement | Apply the supported Medicare or payer-specific reporting pathway |
| Certification discrepancy | Performing location and FDA certification information | Resolve enrollment or certification data with supporting evidence |
For CPT code 77067, assign the denial to its cause rather than putting every rejected claim into an appeal queue. A diagnosis-pointer error and a disputed coverage decision require different work.
Also distinguish a claim that couldn’t be processed from a processed coverage denial. The payer’s instructions determine whether to submit a corrected claim, request reprocessing or pursue an appeal.
Turn individual corrections into actionable controls
Maintain clear queue labels such as “indication conflict,” “missing DBT base,” “component overlap,” and “certification mismatch.” Capture the evidence needed to resolve each instance.
If multiple claims share the same cause, investigate field/interface mapping. Correcting a single claim without resolving a repeated mapping issue leaves the same problem in other claims.
An internal review of CPT code 77067 should include paid claims. Payment does not indicate the reported component, reduced service, or screening diagnosis was warranted.
Eliminate antiquated charge template choices
G0202 is not an alternative screening code for the Medicare reporting described in this document. Removal of CAD codes 77051 and 77052 should also prevent the service from being charged.
Review the pathways that create charges, including selections made in the scheduling system, mappings in the radiology system, and manual entry and claim correction tools. Removing an outdated choice from one screen does not address an interface that creates the choice in another. Focus on maintaining the description for the intended service to allow staff to identify it rather than rely on an obsolete code.
Pre-submission checklist for screening mammography claims
Review this checklist to confirm the record and claim are congruent:
- Does the indication support 77067 as a screening code?
- Does the report identify the examination actually performed?
- Do the diagnosis pointers support each service line?
- Is CAD included in the service and not billed as a separate service?
- Is supported screening DBT paired with the base mammography code?
- Are units consistent with the examination (i.e. number of views) and not with the breast (i.e. number of breasts) or images (i.e. number of images)?
- Do component modifiers reflect the work of the reporting entity?
- Is unilateral screening done under the payer’s reduced-service instructions?
- Does any conversion claim meet all the reporting conditions?
- Are beneficiary eligibility and facility certifications confirmed?
- Are deleted mammography codes removed from active templates?
Have unresolved issues been assigned an owner? An indication conflict requires clinical resolution, whereas a component modifier overlap needs coordination among the billing entities. Neither of these is resolved by selecting a modifier randomly.
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Frequently asked questions
What is CPT code 77067 used for?
CPT code 77067 reports bilateral screening mammography, including two views of each breast and CAD if performed. It supports screening rather than evaluation of a breast symptom. The clinical indication, examination and report must agree; an appointment labeled screening doesn’t independently establish that the screening code is appropriate.
What is the difference between 77067 and 77066?
Code 77067 identifies bilateral screening mammography. Code 77066 identifies bilateral diagnostic mammography performed to evaluate a documented concern. Unilateral diagnostic mammography uses 77065. Choose the procedure from the examination’s purpose and scope rather than the patient’s preferred benefit or a scheduling label that conflicts with the clinical record.
Can 77063 be billed without 77067?
Screening tomosynthesis code 77063 is an add-on and requires its qualifying screening mammography base procedure. For the applicable mammography pairing, report it with CPT code 77067. Verify that the report supports DBT and that component reporting and diagnosis pointers agree across the related claim lines.
Does CPT code 77067 require modifier 33?
Modifier 33 generally isn’t needed because the code already identifies screening. Follow the payer’s documented instructions rather than adding it automatically. Other modifiers address different circumstances, including professional interpretation, technical work, reduced services and qualifying conversion claims. A modifier should communicate a supported billing circumstance, not manufacture preventive eligibility.
Which ICD-10-CM diagnosis supports CPT code 77067?
Z12.31 generally supports an encounter specifically for screening mammography. Additional documented risk or history information may be reportable under the applicable classification instructions. Evaluate each procedure’s diagnosis pointer. Don’t replace a documented diagnostic indication with a screening diagnosis merely because the claim would receive different benefit treatment.
Is CAD required to report CPT code 77067?
CAD is included if performed; the wording does not make it mandatory. The examination must otherwise meet the screening mammography description and be supported by the report. Don’t add a separate CAD charge for the same mammography service or assume that software assistance changes a screening examination into diagnostic imaging.
Build claim accuracy into the mammography workflow
Although CPT code 77067 allows for numerous modifiers to explain clinical indications, the billing of this code often relies on the radiologist’s inclusion of various components in the examination record. Reliable billing for this code requires: 1) the inclusion of necessary and sufficient clinical indications, diagnosis pointers, and benefit verification; and 2) the radiologist’s attestation (in the examination record) to the inclusion of those components. A modifier list does not provide for either of those requirements.
The examination record is used to select the service, the payer’s rules are used to validate reporting, and the applicable fee schedule or contract is used to assess payment. This gives the billing team a clear basis to correct errors and challenge unsupported denials.
