Corporate

September 6, 2013 - Revised: 01.13.15

Breast Tomosynthesis: Coverage and Claim Submission Instructions

Medicare provides for coverage of diagnostic and screening mammograms, as outlined in the CMS National Coverage Determination (NCD) for Mammograms.

  • The NCD specifies that diagnostic mammograms may be covered for men or women with "signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease."
  • Screening mammograms are those provided in the absence of signs or symptoms of breast disease. Frequency limitations and age specifications apply for Medicare coverage of screening mammograms; refer to the NCD for additional information.

Digital breast tomosynthesis may be performed in addition to digital mammography in order to provide a better image of dense, overlapping, normal breast tissue especially in patients where cancer is a significant concern. CGS has evaluated evidence related to the efficacy of digital breast tomosynthesis, and effective 9/13/2013, this procedure is considered investigational and will be non-covered for routine use. In patients where cancer is a significant concern, as delineated in the NCD, digital tomosynthesis may be covered when utilized as an adjunct to diagnostic mammography in select patients.

Claim submission:

  • Submit claims for digital breast tomosynthesis with one of the following HCPCS codes (including appropriate modifiers):
    • G0202: Screening mammography, producing direct digital image, bilateral, all views
    • G0204: Diagnostic mammography, direct digital image, bilateral, all views
    • G0206: Diagnostic mammography, producing direct digital image, unilateral, all views

Resources and references:


Two Vantage Way, Nashville, TN 37228 © CGS Administrators, LLC. All Rights Reserved