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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.15 Mammography (Screening and Diagnostic Studies of the Breast)

8.2.15
Mammography (Screening and Diagnostic Studies of the Breast)
The following breast imaging studies are benefits of Texas Medicaid:
A screening mammogram may be billed using procedure code 77057 or G0202. Procedure code 77057 will be denied when billed if it is submitted for the same date of service as procedure code G0202 by any provider.
Note:
A diagnostic mammogram may be billed using procedure code 77055, 77056, G0204, or G0206.
Procedure code 77055 will be denied if it is submitted for the same date of service as procedure code 77056, G0204, or G0206 by any provider.
Procedure code 77056 will be denied if it is submitted for the same date of service as procedure code G0204 by any provider.
Procedure code G0206 will be denied if it is submitted for the same date of service as procedure code 77056 or G0204 by any provider.
Screening mammograms may be reimbursed for the same date of service as a diagnostic mammogram if the diagnostic mammography procedure codes are submitted with a GG modifier.
A mammogram may be indicated for a male client based on medical necessity due to existing signs and symptoms. In such rare circumstances, procedure codes 77055, 77056, G0204, and G0206 may be considered for reimbursement.
Other breast diagnostic radiology procedures may be medically necessary based on existing signs and symptoms. When indicated, such procedures may be considered for reimbursement using procedure code 76098, 77031, 77032, 77053, or 77054. Procedure code 77053 will be denied if it is submitted for the same date of service as procedure code 77054 by any provider. Procedure code 76098 may be reimbursed for both male and female clients.
Computer‑aided detection (CAD) procedure codes 77051 and 77052 may be reimbursed in addition to screening and diagnostic mammography.
Procedure codes 77051 and 77052 are add‑on codes and must be submitted with the primary procedure code to be considered for reimbursement. Procedure code 77051 must be submitted for reimbursement with procedure code 77055, 77056, G0204, or G0206. Procedure code 77052 must be submitted for reimbursement with procedure code 77057 or G0202.
Breast ultrasound may be considered for reimbursement using procedure code 76645.
Authorization is not required for these services.
The prescribing physician must maintain documentation of medical necessity in the client’s medical record. The radiologist or interpreting physician at the testing facility may determine and document that, because of the abnormal result of the diagnostic test performed, additional studies are medically necessary. The radiologist or interpreting physician ordering the additional studies must provide documentation to the prescribing physician.

Texas Medicaid & Healthcare Partnership
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