CPT® Code 77067

Quick Reference

• Code definition: CPT 77067 covers bilateral screening mammography, two views per breast (craniocaudal and mediolateral oblique), with computer-aided detection (CAD) bundled when performed, for asymptomatic patients only.
• Key billing rule: MUE = 1; report once per date of service regardless of whether CAD was used. CAD is included in the descriptor and is never separately reportable [4].
• Modifier essentials: Modifier 26 for the radiologist's professional component when split-billed; modifier TC for the technical component. Append modifier GG to the diagnostic code (not 77067) when a screening encounter converts to diagnostic in the same visit [2].
• Documentation must-have: The medical record must confirm asymptomatic status. Any documented symptom (lump, pain, nipple discharge) reclassifies the service as diagnostic, requiring 77065 or 77066.
• Top confusion point: Do not default to 77067 because the order reads "screening." If clinical documentation reveals a breast symptom, the diagnostic code applies regardless of the ordering language.
• Payer alert: Medicare covers bilateral screening under NCD 220.4 with no Part B deductible or coinsurance. When a screening converts to diagnostic, the diagnostic portion becomes subject to standard cost-sharing [1].
• Add-on: 77063 (screening digital breast tomosynthesis, bilateral) is reported in addition to 77067 when 3D tomosynthesis is performed. It cannot be reported as a standalone service.

When to Use This Code

77067 applies when an asymptomatic patient presents solely for routine breast cancer detection. There must be no palpable mass, no breast symptoms, and no prior imaging finding that prompted the visit. The study must include two standard views of each breast; partial studies (one view per breast or one breast) fall outside this descriptor.

CAD is bundled regardless of whether the radiology system performed algorithmic analysis. Do not append a separate CAD code or otherwise seek separate reimbursement for CAD since 2017.

The screening designation governs financial liability for Medicare beneficiaries: the ACA similarly prohibits cost-sharing for covered preventive services coded as screening under USPSTF Grade B recommendations [1]. Miscoding an asymptomatic patient's screening as diagnostic, or coding a symptomatic patient's diagnostic work as screening, carries compliance and financial consequences in both directions.

77067 is bilateral by definition. It cannot represent a single-breast study. For patients who have had a prior mastectomy and present for screening of the remaining breast, verify payer policy; some payers require 77065 with appropriate documentation rather than 77067.

Code Differentiation Table

The single most critical differentiator is patient presentation. Screening versus diagnostic is not determined by technique, equipment, or the order form; it is determined by whether the patient has a current breast complaint or a prior imaging finding requiring follow-up. Coders must review the clinical note, not just the order.

flowchart TD
    A[Patient presents for mammography] --> B{Breast symptom or\nprior suspicious finding?}
    B -- Yes --> C{One or both breasts?}
    C -- One --> D[77065\nDiagnostic Unilateral]
    C -- Both --> E[77066\nDiagnostic Bilateral]
    B -- No --> F[77067\nScreening Bilateral]
    F --> G{3D tomosynthesis\nperformed?}
    G -- Yes --> H[77067 + 77063]
    G -- No --> I[77067 only]

Billing & Modifier Rules

Professional and technical component split-billing: PC/TC Indicator = 1 applies to 77067. When the radiologist and the facility are separate billing entities, each bills the applicable component modifier [3]:

• Modifier 26: radiologist's interpretation only
• Modifier TC: facility's equipment, staff, and image acquisition
• No modifier (global): single provider who owns the equipment and performs the interpretation

Both components cannot be billed by the same entity for the same service. The sum of 26 and TC equals the global payment.

Modifier GG and the screening-to-diagnostic conversion: When screening images prompt additional diagnostic views during the same encounter, Medicare permits reporting both services [2]:

• 77067 with Z12.31 (the screening portion)
• 77065 or 77066 with modifier GG and an appropriate finding or symptom diagnosis (the diagnostic portion)

GG is appended to the diagnostic code, not to 77067. Omitting GG results in denial of one of the two services. This conversion scenario is among the most frequently audited patterns in breast imaging billing.

Add-on code 77063: Append 77063 when digital breast tomosynthesis (3D) images are acquired bilaterally during the same screening encounter. 77063 carries Global = ZZZ, confirming it is an add-on and cannot be reported independently. CPT guidelines explicitly state to use 77063 in conjunction with 77067 [6].

MUE and bilateral payment adjustments:

• MUE = 1: only one unit of service per beneficiary per date of service [4]
• Bilateral Surgery Indicator = 2: the 150% bilateral payment adjustment does not apply; the bilateral nature is inherent in the single-code descriptor

CAD bundling: Since the 2017 code restructure, CAD is part of the 77067 descriptor. Separately billing any CAD code alongside 77067 is an unbundling violation [4].

Documentation Essentials

The key documentation burden for 77067 is establishing the screening designation, not the technical performance of the study.

Required elements:

• Explicit or clearly implied asymptomatic status; "no breast complaints," "routine annual screening," or equivalent language in the clinical note
• Two views documented per breast (CC and MLO); the descriptor specifies a 2-view study
• Radiologist interpretation and signed report for the professional component
• Patient age and sex, supporting Medicare frequency eligibility
• Date of prior mammogram if available, to confirm the 12-month window has elapsed

Audit red flags: Auditors flag 77067 when the clinical note documents any of the following in the same encounter: a new breast lump, nipple discharge, skin changes, breast pain, or a prior BI-RADS 0, 3, 4, or 5 result that prompted the visit. When those elements are present and the claim reports 77067, reviewers reclassify the service as diagnostic and recover the payment differential.

A second audit pattern involves G0202 claims appearing after 12/31/2017. CMS edits will auto-deny the deleted code, but post-payment audit recoveries also target facilities that were slow to update charge masters.

Medical necessity: For Medicare, clinical necessity for the screening frequency (annual starting at age 40, one baseline between 35 and 39) must be supported by documentation consistent with NCD 220.4 [1]. High-risk status (family history such as Z80.3 or personal history such as Z85.3) may support payer-specific enhanced frequency under commercial or Medicare Advantage plans but does not independently override Medicare Original's NCD frequency limits.

Medicare, Commercial & Medicaid Payer Rules

Medicare

Under NCD 220.4 [1], Medicare Part B covers:

• One baseline screening mammogram for female beneficiaries aged 35 to 39
• One annual screening mammogram per 12-month period for female beneficiaries aged 40 and older

The beneficiary must be female; 77067 is not a covered Medicare benefit for male beneficiaries as a screening service. The ordering provider does not need to be present at the time of service; the mammography facility bills directly.

The screening portion carries no Part B deductible or coinsurance. If the encounter converts to a diagnostic study, the diagnostic claim (77065 or 77066 with modifier GG) is subject to standard Part B cost-sharing [2]. This has direct patient financial impact and is a source of patient complaints when facilities fail to explain the cost-sharing shift at the time of service.

CMS replaced the prior HCPCS code G0202 with CPT 77067 effective 2017-01-01 [3]. Facilities that retained G0202 in their charge masters after that date incurred systematic claim denials.

Commercial payers

Under ACA Section 2713, non-grandfathered health plans must cover USPSTF Grade A and B preventive services, including screening mammography, with no cost-sharing when reported as a screening service with Z12.31. If the claim is submitted with a diagnostic code instead, the ACA cost-sharing waiver does not apply and the patient incurs out-of-pocket expense. This distinction is a source of patient disputes and payer audits.

Commercial payers vary on coverage age thresholds, frequency, and high-risk protocols. Some plans cover annual screening beginning at age 40; others follow USPSTF biennial guidance. Verify plan-specific policies before assuming Original Medicare rules apply.

Medicare Advantage

Medicare Advantage plans must provide at minimum the same benefit structure as Original Medicare for screening mammography. Many plans expand coverage (lower age thresholds, annual frequency for average-risk patients, or coverage for high-risk supplemental screening). Do not assume Original Medicare NCD 220.4 frequency rules govern all Medicare Advantage claims.

Common Denials & Prevention

Frequency exceeded (Medicare)

Why it happens: The prior mammogram was billed fewer than 12 months before the current date of service, triggering an automatic edit under NCD 220.4 [1]. This occurs when annual exams are scheduled slightly early or when a prior facility's claim was not visible to the billing staff.

Prevention: Verify the date of the beneficiary's last Medicare-covered mammogram before submission. If a prior mammogram was performed at a different facility, confirm through the Medicare Beneficiary Identifier (MBI) history or beneficiary records. For patients who have had a diagnostic mammogram (77065/77066) within the same year, that does not reset or block the annual screening benefit.

Asymptomatic claim denied as incorrect code

Why it happens: The clinical documentation contains a mention of a symptom, prior BI-RADS 0 recall, or a finding that prompted the referral, making 77067 unsupported on audit. The denial comes post-payment as a recovery, not always at the point of adjudication.

Prevention: Review the clinical note, not just the order, before assigning 77067. If any breast symptom is documented, code 77065 or 77066 with the appropriate diagnosis.

Missing modifier GG on converted diagnostic

Why it happens: The radiologist orders additional views based on screening findings; the coder submits 77067 and 77066 without GG on the diagnostic code. Medicare's system cannot reconcile two mammography codes on the same date without the GG modifier and denies one service [2].

Prevention: Build a workflow that flags same-day mammography code pairs. GG must be on the diagnostic code. Brief radiologists and coders on the requirement to document the conversion clearly in the radiology report.

CAD billed separately

Why it happens: A legacy charge master or coding template includes a separate CAD code that pre-dates the 2017 restructure, and it fires automatically alongside 77067.

Prevention: Audit charge masters for any CAD-specific codes pairing with 77067 and deactivate them. Since 2017, CAD is bundled in the descriptor and separately reportable CAD codes will be denied or constitute an overpayment [4].

Legacy G0202 on claims after 12/31/2017

Why it happens: Charge masters or billing systems were not updated when the code was deleted.

Prevention: G0202 was deleted effective 12/31/2017 [4]. Any claim using G0202 after that date will auto-deny. Replace with 77067 and resubmit; do not attempt to hold for appeal, as the code is simply invalid.

Coding Scenarios

Scenario 1: Routine annual screening, radiologist employed by independent group

A 58-year-old asymptomatic woman presents at a hospital outpatient imaging center for her annual mammogram. Two views per breast are acquired. CAD is applied by the digital system. The radiologist is employed by an independent radiology group and bills separately from the facility.

Correct coding: Facility: 77067-TC with Z12.31. Radiology group: 77067-26 with Z12.31.

Why: PC/TC Indicator = 1 allows split-billing. CAD is bundled and not separately reportable. TC plus 26 must not be billed by the same entity.

Scenario 2: Screening with 3D tomosynthesis

A 45-year-old asymptomatic woman with dense breast tissue presents for annual screening at a facility using a combined 2D/3D mammography unit. Standard CC and MLO views are acquired per breast along with tomosynthesis images of both breasts.

Correct coding: 77067 + 77063 with Z12.31.

Why: 77063 is an add-on code specifically for bilateral screening tomosynthesis and is used in conjunction with 77067. It cannot be reported without the primary service. Both codes carry MUE = 1.

Scenario 3: Screening converts to diagnostic during the same encounter

A 65-year-old Medicare patient presents for screening. Standard bilateral images are acquired and interpreted. The radiologist identifies an asymmetry in the left breast and orders additional spot-compression views during the same visit. The additional views are performed and interpreted.

Correct coding: 77067 with Z12.31 for the screening portion; 77065-GG with an appropriate finding code (e.g., R92.8 or an N63.xx lump code depending on the radiologist's documentation) for the diagnostic portion.

Why: Medicare allows both codes on the same date when GG is appended to the diagnostic code [2]. The screening service carries no cost-sharing; the diagnostic portion is subject to Part B deductible and coinsurance. GG must be on the diagnostic code, not on 77067.

Scenario 4: Patient presents with breast lump, order reads "screening"

A 52-year-old woman is referred for "screening mammography." Her clinical note from the referring provider documents a palpable lump in the right upper outer quadrant. Two views per breast are obtained.

Correct coding: 77065 (unilateral diagnostic, right) with N63.11 (unspecified lump, right breast, upper outer quadrant), or 77066 if bilateral diagnostic views were medically indicated.

Why: The order language does not determine code selection. Clinical documentation of a palpable lump establishes a symptomatic presentation; 77067 is unsupported and would constitute an incorrect claim. Z12.31 Excludes1 does not include R92.2, but more critically, screening codes are not appropriate when a symptom drives the visit.

Related Codes

• 77065: Diagnostic mammography, unilateral, CAD included; use when the patient has a unilateral breast symptom or prior finding
• 77066: Diagnostic mammography, bilateral, CAD included; use when the patient has a bilateral or unspecified symptomatic indication
• 77063: Screening digital breast tomosynthesis, bilateral; add-on reported in addition to 77067 when 3D tomosynthesis is performed
• G0202: Deleted HCPCS predecessor to 77067; deleted 12/31/2017
• Z12.31: Encounter for screening mammogram; primary diagnosis for asymptomatic bilateral screening
• Z12.39: Encounter for other screening for malignant neoplasm of breast; alternate screening encounter diagnosis
• Z80.3: Family history of malignant neoplasm of breast; supporting diagnosis for high-risk screening protocols
• Z85.3: Personal history of malignant neoplasm of breast; secondary diagnosis for survivors undergoing surveillance screening
• R92.2: Inconclusive mammogram; used for inconclusive findings; Excludes1 relationship with Z12.31 prevents simultaneous use

Sources {#sources}

1. NCD 220.4 – Mammography — CMS Medicare Coverage Database. Coverage criteria, frequency limits, and eligibility requirements for screening mammography.
2. CMS Medicare Claims Processing Manual, Chapter 12 — CMS. Billing rules for modifier GG and the screening-to-diagnostic conversion.
3. CMS Physician Fee Schedule — CMS. Status indicators, PC/TC rules, and payment rates for 77067.
4. CMS NCCI Policy Manual for Medicare Services — CMS. Bundling rules, MUE values, and CAD unbundling guidance.
5. ACR Practice Parameter for the Performance of Screening and Diagnostic Mammography — American College of Radiology. Clinical indications and imaging standards.
6. AMA CPT Assistant – Mammography coding guidance — AMA. Official CPT coding guidance for the 77065 to 77067 code restructure effective 2017.