CPT codes are standardized identifiers used throughout the U.S. healthcare system to describe medical services and procedures for administrative and billing purposes. CPT code 77065 is the designated identifier for a diagnostic mammography performed on a single breast, formally known as a unilateral diagnostic mammography. The code includes Computer-Aided Detection (CAD), which uses software to assist the interpreting radiologist. Understanding the specifics of this code dictates how the service is classified and billed.
Defining Diagnostic Mammography
Diagnostic mammography is an advanced form of breast imaging used to investigate a specific area of concern within the breast tissue. Unlike a routine screening, this procedure is focused and often requires a radiologist to be present during the exam to guide the technologist in real-time. The process involves specialized views, such as magnification or spot compression, to obtain a clearer, more detailed image of a localized region. These focused images help the radiologist thoroughly evaluate a known abnormality, such as a palpable lump, pain, or a suspicious finding from a prior exam.
The equipment used is the same as for a screening exam, but the approach shifts from a general survey to a detailed investigation. The unilateral nature of CPT code 77065 means the imaging is concentrated on only one breast, typically the one exhibiting the symptom or abnormality. This detailed focus allows for a precise characterization of the area, which is necessary before deciding on a next step. The procedure is intended to be a problem-solving tool to arrive at an accurate diagnosis of a condition.
The Key Difference Between Diagnostic and Screening
The fundamental distinction between a diagnostic and a screening mammography lies in the patient’s symptoms and the purpose of the exam itself. Screening mammography (CPT 77067) is a preventative measure performed on asymptomatic patients for routine surveillance. The goal of screening is to detect breast cancer early, before any physical symptoms are apparent. Screening exams are usually bilateral, imaging both breasts, and consist of only two standard views of each breast.
In contrast, diagnostic mammography, identified by codes like 77065, is an investigative procedure performed on patients who have symptoms or an abnormal finding on a previous test. The intent is diagnosis, as the physician determines the cause of a problem. This shift in purpose changes the procedure from a routine check to a medically necessary workup, requiring additional views and focused attention. This difference guides the choice between the screening and diagnostic codes during the billing process.
Clinical Reasons for Using Code 77065
A diagnostic mammogram is ordered when a specific clinical concern requires a focused examination of one breast. One of the most common reasons is to follow up on an abnormal result from a recent screening mammogram, such as a newly detected mass, suspicious calcifications, or architectural distortion in the tissue. The code is also used when a patient presents with a new physical symptom, which may include a palpable lump or mass in one breast.
Other indications for ordering a unilateral diagnostic mammogram include localized breast pain, nipple discharge, or a change in the skin texture of one breast. CPT 77065 may also be used for patients who have a history of breast cancer and require annual surveillance of the remaining breast tissue. The diagnostic procedure assesses the specific area of concern, allowing the radiologist to determine if the finding is benign or requires further intervention.
Billing Implications and Patient Responsibility
The classification of a mammogram as diagnostic has a significant impact on how the service is billed and the patient’s out-of-pocket costs. Under the Affordable Care Act, screening mammography is covered by insurance at 100% with no cost-sharing for the patient, as it falls under preventative care mandates. However, diagnostic mammography (CPT 77065) is considered an investigative service for a specific medical condition, not a preventative measure.
Therefore, diagnostic procedures are subject to the patient’s standard cost-sharing responsibilities, including deductibles, copays, and coinsurance. If a screening mammogram is converted to a diagnostic one on the same day due to an immediate finding, a billing modifier may be used, but the diagnostic portion of the service will still incur a cost. Because coverage rules vary widely, patients should always contact their insurance provider to confirm their exact financial responsibilities before the procedure is performed.