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Update to EWC Diagnostic and Screening Mammography Benefits

November 20, 2017

Effective for dates of service on or after October 1, 2017, the following CPT-4 codes are no longer reimbursable by the Every Woman Counts (EWC) program:

CPT-4 Code Description
77055 Mammography; unilateral
77056 Mammography; bilateral
77057 Screening mammography; bilateral

Effective for dates of service on or after October 1, 2017, the following CPT-4 codes are reimbursable by the EWC program:

CPT-4 Code Description
77065 Diagnostic mammography, unilateral, includes CAD
77066 Diagnostic mammography, bilateral, includes CAD
77067 Screening mammography, bilateral

EWC policy for codes 77065 and 77066 is as follows:

  • Reimbursable if one of the following applies:
    • The recipient has distinct signs and symptoms for which a diagnostic mammogram is indicated, or
    • The recipient has a history of breast cancer, or
    • The recipient is asymptomatic, but on the basis of the recipient’s history and other significant factors in the physician’s judgment, a diagnostic mammogram is indicated and appropriate
  • Codes 77065 and 77066 are not reimbursable when billed for the same day for the same recipient
  • Limited to two procedures per year per provider. An approved Treatment Authorization Request (TAR) can override the frequency limit for code 77066

EWC policy for code 77067 is as follows:

  • Limited to one screening per year, any provider, unless overridden with an approved TAR
  • Reimbursable with modifiers U7 and 99, as appropriate
  • Not separately reimbursable with HCPCS code G0202 (digital screening mammography)
  • Restricted to individuals 40 years of age or older

The Medi-Cal claims processing system is being updated to process claims with CPT-4 codes 77065 – 77067. Once the system is ready, denied claims submitted for dates of service on or after October 1, 2017, will be subject to an Erroneous Payment Correction (EPC).

Provider manual and EWC document updates will be announced in a future Medi-Cal Update.