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36.4.9.12 Screening and Diagnostic Studies of the Breast
The following breast imaging studies are benefits of the Texas Medicaid Program:
• Screening mammogram. Used to look for breast disease in women who are asymptomatic. (Note: The American Cancer Society recommends annual screening mammography for woman beginning at 40 years of age.)
•Diagnostic mammogram. Used to diagnose breast disease in those women or men who have breast symptoms or findings on physical exam.
•Digital Mammography. used to assist diagnosis and further localization of lesions and areas of suspicion when performing screening and diagnostic mammography.
•Diagnostic breast ultrasound. Used to evaluate breast abnormalities that are found with screening or diagnostic mammography.
Mammography: Screening, Diagnostic, and Digital
Mammography is an essential appropriate diagnostic radiology technique for breast cancer detection.
To maximize the diagnosis of breast cancer at the earliest time, the diagnostic radiology procedure of mammography must be used on a reasonable basis in a timely manner. Physical examination supplemented by patient self-examination remains the principle diagnostic modality for women with an examination every year.
After 35 years of age, the physical examination should be augmented by the diagnostic radiology procedure of mammography on the following nationally recognized schedule, even if no symptoms are present:
Mammography is payable with an appropriate diagnosis.
The use of mammography as an augmentation to the physical examination on the schedule above is limited to females.
Procedure code 4/I/T-77057 may be used for a screening mammogram, and procedure codes 4/I/T-77055 or 4/I/T-77056 may be used for a diagnostic mammogram.
Other breast diagnostic radiology procedures may be medically necessary based on existing signs and symptoms. When indicated, such procedures may be considered for reimbursement. However, the mammography codes 4/I/T-77055, 4/I/T-77056, and 4/I/T-77057 are denied when submitted with the same date of service as diagnostic radiological procedure codes 4/I/T-76098, 4/I/T-77031, 4/I/T-77032, 4/I/T-77053, and 4/I/T-77054.
Digital mammography may be considered for reimbursement in addition to screening and diagnostic mammography when submitted with procedure codes 4/I/T-77051 and 4/I/T-77052.
Ultrasound may be considered for reimbursement using procedure code 4/I/T-76645.
A mammogram may be indicated in a male client, based on medical necessity because of existing signs and symptoms. In such circumstances, the procedure codes 4/I/T-77055 and 4/I/T-77056 are considered for reimbursement.
A mammogram may be medically necessary based on existing signs and symptoms, and may be performed without regard to the above schedule when medically indicated.
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