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Effective March 1, 2021, Procedure Codes 77063 and G0279 to Become Benefits of Texas Medicaid and HTW

Last updated on 1/15/2021

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after March 1, 2021, digital breast tomosynthesis procedure codes 77063 and G0279 will become a benefit of Texas Medicaid and Healthy Texas Women (HTW).

Screening Mammogram

Digital breast tomosynthesis (DBT), also known as three-dimensional (3D) mammography, provides 3D images and is a modification of conventional mammography. Screening DBT is used, along with conventional screening mammography, to detect breast changes in women who have no signs or symptoms of breast cancer. 

Diagnostic Mammogram

Diagnostic DBT is used, along with conventional diagnostic mammography, to diagnose breast disease in women or men who have breast symptoms or findings on physical examination or screening mammogram.

Reimbursement

Procedure code 77063 may be reimbursed as follows:

Type of Service

Place of Service

Provider Type

Total Component

Office

Physician assistant, nurse practitioner, clinical nurse specialist, physician, portable X-ray, radiological lab and physiological lab

Total Component

Outpatient Hospital

Hospital

Professional Component

Office

Physician assistant, nurse practitioner, clinical nurse specialist, and physician

Professional Component

Inpatient and Outpatient Hospital

Physician

Technical Component

Office

Physician assistant, nurse practitioner, clinical nurse specialist and physician, portable X-ray, radiological lab and physiological lab

Family planning clinic providers may also be reimbursed for services rendered in the office setting for HTW.

Procedure code 77063 must be billed with primary procedure code 77067. Reimbursement may be considered for procedure code 77063 when performed on the same date of service, by any provider, as procedure code 77067.

Procedure codes 77063 and 77067 will be limited to one per rolling year, any provider.

Procedure code G0279 may be reimbursed as follows:

Type of Service

Place of Service

Provider Type

Total Component

Office

Physician assistant, nurse practitioner, clinical nurse specialist, physician, portable X-ray, radiological lab and physiological lab

Total Component

Outpatient Hospital

Hospital

Professional Component

Office

Physician assistant, nurse practitioner, clinical nurse specialist, and physician

Professional Component

Inpatient and Outpatient Hospital

Physician

Technical Component

Office

Physician assistant, nurse practitioner, clinical nurse specialist and physician

Family planning clinic providers may also be reimbursed for services rendered in the office setting for HTW.

Procedure code G0279 must be billed with primary procedure code 77065 or 77066. Reimbursement may be considered for procedure code G0279 when performed on the same date of service, by any provider, as procedure code 77065 or 77066.

Reimbursement may be considered for a screening mammogram (procedure code 77063 or 77067) performed on the same patient on the same date of service as a diagnostic mammogram (procedure code 77065, 77066, or G0279), by submitting the diagnostic mammography with the modifier GG.

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 77065, 77066, and G0279 may be considered for reimbursement.

For more information, call the TMHP Contact Center at 800-925-9126.