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Revised: Update to Screening Mammography Reimbursement Restrictions

March 14, 2016

An article published in the February 2016 Medi-Cal Update announced that, effective for dates of service on or after March 1, 2016, reimbursement for screening mammograms is restricted to females 50 to 74 years of age. This announcement was not compliant with the Consolidated Appropriations Act of 2016 (House Resolution 2029).

Providers should continue to provide mammography services. Breast cancer screening mammography for females 40 years of age and older every one to two years is reimbursable. This change will be made effective in a future Medi-Cal Update.

Effective immediately, Medi-Cal’s policy on reimbursement for screening mammograms is consistent with the U.S. Preventive Services Task Force’s 2002 recommendation of breast cancer screening mammography every one to two years for women 40 years of age and older. The revised policy applies to the following codes:

CPT-4 Code Description
77052 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation, with or without digitization of film radiographic images; screening mammography
77057 Screening mammography, bilateral (2-view film study of each breast)
77063
Screening digital breast tomosynthesis, bilateral
HCPCS Code Description
G0202 Screening mammography, producing direct digital image, bilateral, all views

There are no diagnostic restrictions for screening mammograms. An approved Treatment Authorization Request (TAR)may override gender and age restrictions. Providers should continue to submit claims timely. If applicable, affected claims for recipients 40 to 50 years of age will be processed separately, which may delay reimbursement.

Providers should continue to check the Medi-Cal website regularly for updates.