Current Procedural Terminology (CPT) codes are the standardized language used to describe medical services and procedures for administrative and billing purposes across the United States. Maintained and updated by the American Medical Association (AMA), these codes are fundamental for communication between healthcare providers and payers, including insurance companies and government programs. CPT 77065 is a specific code designated for a distinct, non-routine procedure within the field of breast imaging, signifying a targeted clinical investigation.
Defining CPT Code 77065
The precise description for CPT Code 77065 is “Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral.” This definition establishes two parameters for the service: the purpose is diagnostic, and the scope is unilateral, meaning it focuses on a single breast. Computer-Aided Detection (CAD) indicates that the procedure uses specialized software to help the radiologist analyze the images by highlighting suspicious areas.
Diagnostic mammography is fundamentally different from screening mammography, which is coded separately under CPT 77067. Screening is performed on patients who have no signs or symptoms of breast disease, serving as a preventative measure. Conversely, a diagnostic mammogram is ordered when a patient has a specific symptom or when an abnormality is detected during a prior screening or physical examination. This change in purpose from general surveillance to specific investigation dictates the use of the 77065 code.
The Diagnostic Mammography Procedure
The diagnostic mammogram differs from routine screening due to the specialized nature of the investigation. While a standard screening typically involves two routine views of each breast, the diagnostic study focuses heavily on the area of clinical concern. The technologist, and often the radiologist, are closely involved to tailor the imaging specifically to the suspected abnormality.
The procedure employs specialized techniques to obtain a clearer picture of the concerning tissue. These techniques include magnification views, which provide a closer look at structures like microcalcifications, and spot compression. Spot compression uses a smaller paddle to apply focused pressure on a localized area. This targeted compression helps spread out overlapping breast tissue, allowing the radiologist to better assess the margins and density of a potential mass.
Because the diagnostic examination is customized and involves acquiring multiple, specialized images, the procedure generally takes more time than a screening mammogram. The radiologist’s immediate input is often necessary to determine if enough information has been gathered to make a definitive assessment. The goal is to maximize the visual information from a single breast to resolve the initial clinical concern or recommend further imaging, such as a breast ultrasound.
Clinical Indications and Usage
The decision to use CPT 77065 is driven by medical necessity, requiring the existence of a symptom or a need for follow-up on a previously identified finding. The most common clinical indication is the evaluation of a palpable breast lump or mass discovered by the patient or a physician. A diagnostic mammogram is the initial step in a workup to determine the nature of the mass.
Other specific symptoms prompting the use of this code include persistent, focal breast pain or the presence of spontaneous nipple discharge. The code is also used when a prior screening mammogram (CPT 77067) reveals a suspicious abnormality, necessitating detailed follow-up. In this scenario, the initial screening converts to a diagnostic procedure to characterize the finding, such as a cluster of microcalcifications or an architectural distortion.
Patients with a personal history of breast cancer or those requiring short-interval surveillance for a previously identified lesion also fall under the diagnostic category. The diagnostic study is an active investigation aimed at achieving a specific interpretive conclusion and guiding subsequent management recommendations. The unilateral nature of CPT 77065 is appropriate when the symptoms or abnormality are confined to just one breast.
Billing and Coding Context
CPT Code 77065 is designated for a unilateral diagnostic study. If the diagnostic examination is performed on both breasts, the corresponding code is CPT 77066: “Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral.” The choice between 77065 and 77066 depends solely on whether one or both sides are imaged, based on the physician’s order.
To ensure accurate billing, CPT 77065 requires the use of modifiers to specify the exact side being imaged. Modifiers like -RT (right side) or -LT (left side) are appended to the code to indicate which breast received the service. If a patient arrives for a screening mammogram (77067) but an abnormality necessitates a diagnostic workup on the same day, a special modifier, such as GG, may be used. This modifier indicates that the screening procedure was converted to a diagnostic one, which is important for proper coverage and payment determination.