• In the U.S.A, under the Affordable Care Act (Obamacare), insurance carriers are required to cover the full cost of a screening mammogram. A screening mammogram is for women with no symptoms. If the screening is performed by 3D/tomosynthesis mammography, the full cost might not be covered by some insurance companies. It depends on the state in which you live (click here to learn more) and what insurance you have.
• Insurance coverage for additional screening tests after your mammogram, such as Ultrasound or MRI, varies by state and by insurance company. You should check with your insurance carrier(s) to learn if and how additional tests will be covered.
• For women at high risk for breast cancer, most insurers will cover a screening MRI (regardless of density), though a deductible/co-pay may apply, and pre-authorization may be needed.
• A diagnostic mammogram is for women with a sign or symptom of breast cancer, such as a lump or nipple discharge. A diagnostic mammogram is also used if additional mammography views are needed to clear up a question raised on a screening mammogram. A deductible/co-pay will usually apply for a diagnostic mammogram. But again, it depends on where you live and your insurance plan.

In Europe, national breast screening programs for women of average risk are offered in nearly all countries. Variations do exist on the ages and risk factors of women invited to participate in routine screening, how often screening is recommended, and supplemental screening tools used. For specific information by European country, click here.

Learn More:

• 5 Facts Every Woman Should Know
• Video Series: Let’s Talk About Dense Breasts
• Patient Risk Checklist (print)
• Patient Questions and Answers

• In the U.S.A., medical procedures are billed using both an ICD (International Classification of Disease) code and a CPT (Current Procedural Terminology) code.
• Use those codes to check with your insurance company to learn if a specific test should be covered and what your out-of-pocket costs (copay, deductible, or coinsurance) may be.
• Coverage varies by state and specific insurance plan.

Insurance Billing Codes by Breast Imaging Test

ICD CODE: For women with dense breasts, an appropriate ICD-10 code is R92.3 (which is “Mammographic density found on imaging of breast”). Note: other diagnosis codes may also apply based on medical history.

CPT CODES
Terms you may hear: one breast = unilateral, both breasts = bilateral

Test	CPT Code	Details
2D Mammogram (screening)	77067 (both breasts, 2-views of each)	Code also includes computer-aided detection (CAD) when performed. The Affordable Care Act requires insurers to cover annual screening mammography beginning at age 40, without any out-of-pocket costs. For younger women at high risk, screening mammography typically requires a prescription from a physician and may be subject to out-of-pocket costs.
2D Mammogram (diagnostic)	77065 (one breast) 77066 (both breasts)	Codes also include computer-aided detection (CAD) when performed. Diagnostic mammography is typically subject to out-of-pocket costs. A diagnostic mammogram is monitored by the radiologist and should only be performed for patients with an appropriate indication such as a lump, nipple discharge, other symptom, or to further evaluate or follow-up abnormalities previously noted on breast imaging. Women with a personal history of cancer can have their routine annual mammogram performed as a diagnostic or a screening examination.
3D Mammogram/tomosynthesis (screening)	77067 (2D both breasts) + 77063 (3D both breasts )	Most major insurers cover screening tomosynthesis; additionally, many states now require coverage. Out-of-pocket costs are possible.
3D Mammogram/tomosynthesis (diagnostic)	77065 (2D one breast) + 77061 (3D one breast) 77066 (2D both breasts) + 77062 (3D both breasts) G0279 – 3D (one or both breasts) if Medicare is primary insurance	Out-of-pocket costs usual. A diagnostic 3D mammogram is monitored by the radiologist and should only be performed for patients with an appropriate indication such as a lump, nipple discharge, other symptom, or to further evaluate or follow-up abnormalities previously noted on breast imaging. Women with a personal history of cancer can have their routine annual 3D mammogram performed as a diagnostic or a screening examination.
Contrast-enhanced Mammogram (CEM)	Currently no CPT code	Most CEM is done as part of research studies at this time. In centers offering clinical CEM, billing is often under CPT code 77065 (one breast) or 77066 (both breasts). Out-of-pocket costs usual. Some centers will also bill for the contrast and the contrast injection.
Ultrasound	76641 (per breast)	“Complete” breast ultrasound is used for screening and will be billed for each breast, usually at half the rate for the second breast. Out-of-pocket costs usual in most states. A “limited” breast ultrasound, 76642, is used to evaluate abnormalities or particular areas of concern.
Molecular Breast Imaging, MBI	78800	Out-of-pocket costs usual.
Magnetic Resonance Imaging, MRI (with contrast)	77048 (one breast) 77049 (both breasts)	May require pre-authorization from your health provider. Out-of-pocket costs usual in most states.
Abbreviated MRI (with contrast)	Currently no CPT code unique to abbreviated MRI. The American College of Radiology endorses use of the modifier, “-52” (limited) exam, in combination with full protocol MRI CPT code 77049 (click HERE for more details, page 12).	Many centers will bill directly to the patient (range $200-$600). © DenseBreast-info.org

Updated Nov 3, 2021. DenseBreast-info.org endeavors to provide up-to-date insurance codes; however, codes can change. These codes may not be the most recent version. No representations or warranties of any kind are made, express or implied, about the completeness, accuracy or reliability of this information provided. A patient should always check with their specific insurance provider.

Learn More:

• 5 Facts Every Woman Should Know
• Video Series: Let’s Talk About Dense Breasts
• Patient Risk Checklist (print)
• Patient Questions and Answers

Yes, you may still need more screening if you have dense breasts and/or are at high risk for breast cancer. Ultrasound or especially MRI might find cancer even if your 3D mammogram is “normal.”

It is still important to have your mammogram first, as mammograms sometimes show some cancers that Ultrasound or MRI may not. The combination of tests finds the most cancers.

Learn More:

• 5 Facts Every Woman Should Know
• Video Series: Let’s Talk About Dense Breasts
• Patient Risk Checklist (print)
• Patient Questions and Answers

A “screening” mammogram. Screening mammograms are for women with no signs or symptoms of breast cancer, whether or not they have dense breasts, family history of breast cancer, or other risk factors. In the U.S.A., screening mammograms are fully covered by insurance under the Affordable Care Act for women over the age of 40. They may also be covered for younger women if recommended by their physician and depending on their health insurance policy.

“Diagnostic” mammograms are used when there are signs and symptoms of breast cancer such as a lump, bloody or clear nipple discharge (not milk from breast feeding) or pulling in of the skin or nipple (called retraction). Diagnostic mammograms are also used to look at areas seen on earlier mammograms (like a screening mammogram) that need more pictures or closer follow-up. “Diagnostic” mammograms start with the same images as screening but are reviewed by the radiologist at the time of the mammogram and while the patient is there. A diagnostic mammogram is usually covered by insurance but out-of-pocket costs like a deductible and copay may be required.

Learn More:

• 5 Facts Every Woman Should Know
• Video Series: Let’s Talk About Dense Breasts
• Patient Risk Checklist (print)
• Patient Questions and Answers

Maybe. You should discuss this with your health care provider or Breast Imaging Radiologist. As you get older, your personal risk factors and how you might benefit from more screening after your mammogram may change. It is important to talk about your risk factors every year or two with your health care provider to determine what screening plan is best for you.

Learn More:

• 5 Facts Every Woman Should Know
• Video Series: Let’s Talk About Dense Breasts
• Patient Risk Checklist (print)
• Patient Questions and Answers

For more information about MBI, click here.

Learn More:

• 5 Facts Every Woman Should Know
• Video Series: Let’s Talk About Dense Breasts
• Patient Risk Checklist (print)
• Patient Questions and Answers

No. Thermography is not an accurate test and is not recommended for screening. For additional information on thermography from the United States Food and Drug Administration, click here.

Learn More:

• 5 Facts Every Woman Should Know
• Video Series: Let’s Talk About Dense Breasts
• Patient Risk Checklist (print)
• Patient Questions and Answers