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Erroneous Denial of Mammography Claims

December 6, 2016

The Department of Health Care Services (DHCS) is aware of a claims processing issue causing Medi-Cal and Every Woman Counts (EWC) mammography claims billed with the following CPT-4 codes to erroneously deny with Remittance Advice Details (RAD) code 0095: This service is not payable due to a procedure, or procedure and modifier, previously reimbursed.

Medi-Cal
CPT-4 Code Description
77052 Computer-aided detection with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography
77063 Screening digital breast tomosynthesis, bilateral

Medi-Cal/EWC
CPT-4 Code Description
77057 Screening mammography, bilateral
HCPCS Code Description
G0202 Screening mammography, producing direct digital images, bilateral, all views

This issue affects claims for dates of service on or after September 1, 2013.

DHCS will notify providers when the issue is resolved. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). Providers should continue to submit claims in a timely manner and are encouraged to check the Medi-Cal website regularly for updates regarding this issue.