CPT codes (Current Procedural Terminology) are a standardized language used by healthcare providers and insurance companies for billing and tracking medical services. This system assigns a unique five-digit code to every service a patient receives, from an office visit to a complex operation. The specific code 77067 designates a particular type of breast imaging procedure, communicating to payers exactly what service was rendered. Understanding this code is important for anyone reviewing a medical bill, as it directly impacts coverage and out-of-pocket costs.
The Procedure Explained: Screening Mammography
The full description of CPT code 77067 is “Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed.” This code defines an X-ray imaging procedure intended for early cancer detection in individuals who are not experiencing any breast-related symptoms or abnormalities. A screening mammogram is a preventive service performed on asymptomatic patients to look for early signs of disease, such as small masses or calcifications, that are not yet palpable. The procedure typically involves taking two distinct X-ray views of each breast: the craniocaudal and the mediolateral oblique views.
This standard two-view approach allows radiologists to examine the breast tissue from two different angles, providing comprehensive coverage of the area. The images are captured using either film-screen or digital technology. The inclusion of Computer-Aided Detection (CAD) means specialized software reviews the digital images, highlighting areas that may warrant closer attention from the interpreting radiologist. This technology is integrated into the 77067 code description and is covered under the single charge when used.
A screening mammogram is distinctly different from a diagnostic mammogram, which uses separate CPT codes like 77065 or 77066. Diagnostic imaging is ordered when a patient has specific symptoms, such as a lump or pain, or when a previous screening mammogram or breast exam was abnormal. A diagnostic mammogram often involves additional, specialized views and may be monitored by the radiologist during the procedure to focus on a particular area of concern. This difference in medical necessity is a primary distinction between the two types of procedures and their corresponding billing codes.
Understanding the “Bilateral” Designation
The term “bilateral” in the code description informs the payer exactly what was performed during the procedure. It explicitly means the screening examination was performed on both the right and left breasts during the same session. This is the standard approach for routine screening, as the goal is to examine all breast tissue for early signs of cancer. The code’s bilateral nature differentiates it from procedures that only involve a single breast.
CPT code 77065, for example, is used for a diagnostic mammography that is unilateral, meaning it only examines one breast. Such a unilateral procedure is typically performed as a targeted follow-up to investigate a specific finding. By using 77067, the provider confirms that the imaging covered both sides, fulfilling the requirements for a complete, routine screening.
What This Code Means for Coverage and Billing
CPT code 77067 signals to the insurance company that the service was a preventive screening. Under the Affordable Care Act (ACA) and federal guidelines, most private insurance plans must cover annual screening mammography without patient cost-sharing. When 77067 is correctly submitted, the patient should not be charged a copayment, deductible, or coinsurance for the procedure itself.
The frequency of the screening is subject to specific rules; Medicare generally covers one screening mammogram every 12 months for women aged 40 and older. For a claim to be covered at 100%, the provider must pair CPT code 77067 with the correct diagnosis code, typically one indicating an “encounter for screening.” If the procedure is incorrectly coded as a diagnostic mammogram (77066), the patient may face out-of-pocket costs, even if they had no symptoms.
The correct usage of this code minimizes financial surprises for the patient. If a screening mammogram detects an abnormality and the patient returns for a follow-up diagnostic mammogram (coded 77066), that second procedure may be subject to standard cost-sharing. The 77067 code ensures that the initial, routine, and preventive screening is processed correctly as a fully covered benefit.