Current Procedural Terminology (CPT) codes standardize the documentation of medical procedures, and accurate application is essential for proper reimbursement. Breast imaging presents complex coding situations due to the difference between preventative screening and diagnostic services. This article clarifies the distinction between CPT code 77063 and CPT code 77067, detailing their specific roles in reporting Digital Breast Tomosynthesis (DBT).
Understanding Screening Digital Breast Tomosynthesis
CPT code 77067 represents bilateral screening mammography, the standard two-dimensional (2D) X-ray study of both breasts. This code is reserved for asymptomatic patients who have no signs, symptoms, or personal history requiring immediate clinical investigation. Screening mammography is a preventative service typically performed annually to detect breast cancer early.
CPT code 77063 is the specific code for Digital Breast Tomosynthesis (DBT) when performed during screening. DBT, often called 3D mammography, captures multiple low-dose X-ray images to reconstruct a three-dimensional volume of the breast tissue. This layered technique helps radiologists look past overlapping tissue, benefiting patients with dense breasts.
The core relationship is that 77063 is an “add-on” code billed in addition to the primary screening code, 77067. Together, they represent the complete service of a 2D screening mammogram combined with 3D tomosynthesis. Reporting 77063 alone is incorrect, as it only accounts for the 3D component. Coverage for these services is often limited to one screening per year.
Understanding Diagnostic Digital Breast Tomosynthesis
Diagnostic breast imaging is performed when a patient presents with a specific clinical concern, such as a palpable lump, pain, nipple discharge, or a suspicious finding on a prior screening mammogram. The primary procedure is diagnostic mammography, billed using CPT 77066 (bilateral) or 77065 (unilateral). These codes cover the detailed 2D imaging required to evaluate the area of concern.
Unlike screening, there is no single CPT add-on code for diagnostic DBT universally accepted by all payors. Instead, the diagnostic DBT component is reported using the Healthcare Common Procedure Coding System (HCPCS) code G0279. This code must be billed in conjunction with the primary diagnostic mammography codes (77065 or 77066).
The clinical purpose of diagnostic DBT is to provide a focused, high-resolution evaluation of a suspicious area. The 3D capability helps determine the precise size, shape, and location of an abnormality, aiding the radiologist in determining the need for a biopsy. Diagnostic procedures are not subject to annual frequency limits but must be supported by documented medical necessity.
Clinical Scenarios and Billing Requirements
The distinction between CPT 77063 and 77067 rests entirely on the patient’s clinical status at the time of service. A 50-year-old patient arriving for a routine, annual check-up with no symptoms requires a screening scenario, pairing 77067 (2D screening) and 77063 (3D add-on).
Conversely, a patient presenting with a new, palpable lump requires a diagnostic service. This is reported using the primary diagnostic code (77066 or 77065) alongside the diagnostic DBT code G0279. The codes must always align with the medical reason for the visit.
The primary code used dictates the choice of the appropriate DBT add-on code (77063 or G0279). Failure to match the add-on code to the primary code will result in a claim denial. Screening services are generally limited to one per year, while diagnostic procedures are covered as medically necessary.
A common billing mistake occurs when a patient presents for screening but is found to have a new symptom, necessitating a change to a diagnostic workup. In this instance, the services convert, and the final claim must reflect the diagnostic codes (77066/77065 + G0279). This conversion requires specific documentation and, for Medicare, the use of a modifier.