Digital Breast Tomosynthesis (DBT), often referred to as 3D mammography, captures detailed, layered images of breast tissue, moving beyond traditional two-dimensional X-rays. This technology helps clinicians visualize potential abnormalities with greater clarity by separating overlapping tissue structures. Healthcare systems rely on Current Procedural Terminology (CPT) codes to categorize and bill for these complex medical services. The distinction between different codes for DBT is based entirely on the clinical reason the procedure is performed. Understanding the specific purpose and context of these codes is essential for proper care delivery and billing compliance.
Digital Tomosynthesis for Routine Care
Digital breast tomosynthesis performed as part of a routine examination is categorized using the CPT code 77063. This service is specifically defined as a “screening” procedure, meaning it is conducted on a patient who is asymptomatic and has no known current breast problems or suspicious findings. The primary medical goal of screening is the early detection of breast cancer in the general population, typically recommended on an annual basis for eligible individuals. The tomosynthesis component (77063) is designed to be an enhancement to the standard 2D screening mammogram, which is separately coded as the base procedure (77067).
Because 77063 is an add-on code, it can never be billed alone and must accompany the base screening mammogram code (77067 or a similar code for Medicare beneficiaries). This combined approach leverages the strengths of both 2D and 3D imaging, helping to reduce false positive results and improve cancer detection rates, especially in patients with dense breast tissue. Coverage for screening procedures is often mandated under preventative care guidelines, meaning the frequency of these exams is strictly limited, usually to once every 12 months. The routine nature of this service means the referring physician’s order simply requests a standard annual screening.
Digital Tomosynthesis for Specific Findings
When a patient presents with a specific breast complaint or requires further evaluation due to an abnormal finding, the tomosynthesis procedure shifts from a screening to a diagnostic service. This diagnostic intent is represented by different CPT codes for the tomosynthesis component, such as 77061 for a unilateral exam or 77062 for a bilateral exam. A diagnostic examination is necessary when a patient is symptomatic, perhaps reporting a palpable lump, unexplained breast pain, or nipple discharge, or when a prior screening exam revealed an area of concern. The purpose is to investigate a specific area of concern, localize an abnormality, and determine its nature.
Unlike routine screening, the use of diagnostic codes requires documented medical necessity that justifies the need for the focused investigation. This diagnostic tomosynthesis is often performed in conjunction with a standard 2D diagnostic mammogram, which also uses a different base code than the screening version. Since the procedure is driven by a specific clinical concern, frequency rules differ from screening; a diagnostic tomosynthesis is not limited to an annual schedule and can be performed multiple times within a year if clinically warranted. The referring order must explicitly state the patient’s symptoms or the reason for the follow-up to support the diagnostic designation.
Documentation Requirements and Frequency Rules
The difference in purpose between screening and diagnostic tomosynthesis translates directly into distinct documentation requirements and frequency rules that govern insurance coverage and billing. For screening tomosynthesis (77063), documentation must confirm the patient is asymptomatic and that the exam is being performed for routine preventative purposes. Conversely, diagnostic tomosynthesis (77061/77062) requires robust documentation of the medical necessity, meaning the patient’s chart must clearly include the specific signs, symptoms, or the abnormal finding from a previous exam that prompted the diagnostic workup.
A patient generally cannot be billed for both a screening tomosynthesis (77063) and a diagnostic tomosynthesis (77061/77062) for the same breast on the same day. If an initial screening examination reveals a finding that necessitates an immediate, more detailed diagnostic workup during the same session, the entire encounter is typically converted and billed as a diagnostic service. In conversion cases, special coding modifiers, such as Modifier GG, may be appended to the diagnostic codes to inform the payer that the screening study initiated the process, but the final billed service was diagnostic.
Payer rules regarding frequency also differ significantly. Screening tomosynthesis is typically covered as a preventative benefit with a frequency limit, usually set at one study per year. Diagnostic tomosynthesis, however, is covered under the standard medical benefits, with coverage based on the documented medical necessity rather than a fixed annual limit. The referring provider’s order is also a point of distinction; a screening order is a general request for an annual check-up, while a diagnostic order must be hyperspecific, detailing the clinical reason (e.g., “palpable lump in the upper outer quadrant of the right breast” or “follow-up of BI-RADS 0 finding from prior screening”). These precise documentation requirements are paramount for accurate billing and to prevent claim denials.