Current Procedural Terminology (CPT) codes are standardized five-digit numeric codes used across the United States to describe medical procedures and services for billing and insurance purposes. Understanding these codes is necessary when reviewing a medical bill or an Explanation of Benefits (EOB). CPT Code 77067 reports a screening mammography, bilateral, which includes a two-view study of each breast and computer-aided detection (CAD) when performed. This code is reserved for routine check-ups in asymptomatic patients. The code for a diagnostic mammogram, bilateral is CPT Code 77066, a distinction that significantly impacts the medical and financial aspects of the procedure.
What Diagnostic Mammography Bilateral Means
The term “diagnostic mammography, bilateral” (CPT Code 77066) describes a specialized imaging procedure performed on both breasts, distinct from a standard screening. It is not a routine preventative exam; instead, it is a focused investigation intended to resolve a specific clinical concern. The “bilateral” aspect confirms that imaging is performed on both the right and left breasts, even if symptoms or a prior abnormality were only found in one.
A diagnostic mammogram often involves obtaining more images than the standard two views per breast (cranio-caudal and mediolateral oblique) used in screening. The radiologist is typically present to review initial images and determine if additional, targeted views are necessary. These supplementary images include spot compression views, which flatten a specific area of concern, or magnification views, used to evaluate the characteristics of microcalcifications. These extra steps achieve the highest level of clarity possible for a precise diagnosis.
Clinical Reasons for Code 77067
Diagnostic mammography (CPT 77066) is ordered for several specific medical reasons. The most common indication is the evaluation of a palpable breast lump discovered by the patient or during a clinical breast examination. Any new or suspicious change in breast tissue warrants a diagnostic workup to determine the underlying cause.
Diagnostic mammography is also necessary to investigate symptoms such as focal breast pain that persists beyond one menstrual cycle or spontaneous nipple discharge. Furthermore, if a routine screening mammogram (CPT 77067) reveals an abnormality, such as a mass or suspicious calcifications, the patient is recalled for a follow-up diagnostic mammogram. This procedure further characterizes the initial finding using specialized views and possibly a correlating ultrasound. The physician’s order for CPT 77066 must be supported by documentation detailing these signs or symptoms.
Understanding Diagnostic Versus Screening Mammograms
The difference between a screening mammogram (CPT 77067) and a diagnostic mammogram (CPT 77066) is based on the patient’s clinical status and the procedure’s purpose. Screening is a preventative measure conducted on asymptomatic individuals at average risk for breast cancer, aiming for early detection. Conversely, a diagnostic exam is performed on patients who have a specific sign, symptom, or history, making it a targeted procedure to confirm or rule out a potential diagnosis.
This distinction is important for billing and insurance coverage, as it affects the patient’s out-of-pocket costs. Under the Affordable Care Act (ACA), screening mammograms (77067) are typically covered by insurance with no patient cost-sharing, provided they meet frequency guidelines. Diagnostic mammograms (77066) are considered medically necessary treatment rather than prevention, meaning they are usually subject to the patient’s deductible, copayments, or coinsurance.
Accurate billing relies on the correct CPT code paired with the appropriate diagnosis code, known as the ICD-10 code. A screening mammogram is supported by a screening diagnosis code, such as Z12.31, indicating an encounter for screening. A diagnostic mammogram requires a specific, symptom-based diagnosis code, such as one indicating a palpable mass, to establish medical necessity for the insurance payer. If a claim for a diagnostic service is submitted without a supporting symptom-based ICD-10 code, the claim is likely to be denied.