Summary & Overview
HCPCS G0204: Diagnostic Mammography, Bilateral with CAD
HCPCS Level II code G0204 represents a bilateral diagnostic mammography examination that includes computer-aided detection (CAD) when performed. Nationally, diagnostic mammography is a core imaging service for evaluating symptomatic patients and follow-up of abnormal screening mammograms; accurate coding supports appropriate clinical documentation, claims processing, and population-level tracking of breast diagnostic services. Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of what G0204 denotes, typical sites of service, and the clinical scenarios in which bilateral diagnostic mammography with CAD is used. The publication covers payer coverage considerations, common billing modifiers, and how G0204 relates to service lines in radiology and breast imaging. It also provides benchmarks for utilization and reimbursement context where available, highlights policy updates that affect diagnostic mammography coding and claims, and summarizes practical documentation elements required for accurate coding. Data limitations in the provided input are noted where specific payer rules, associated taxonomies, and ICD-10 mapping are not available. The content is geared toward coders, billing managers, and health policy analysts seeking a clear national-level reference for HCPCS Level II code G0204.
Billing Code Overview
HCPCS Level II code G0204 describes diagnostic mammography, including computer-aided detection (cad) when performed; bilateral. This service is a diagnostic breast imaging study performed on both breasts to evaluate a clinical concern such as a palpable lump, breast pain, nipple discharge, or abnormal screening findings. The service type is diagnostic bilateral mammography with CAD integration. The typical site of service is outpatient imaging centers, hospital radiology departments, and dedicated breast imaging facilities.
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Clinical & Coding Specifications
Clinical Context
A 54-year-old woman presents for a bilateral diagnostic mammogram G0204 after a screening mammogram identified a suspicious area in both breasts. The patient reports a new palpable lump in the left breast and focal nipple discharge on the right. The diagnostic mammogram is ordered by the breast surgeon to further characterize the findings with targeted views and spot compression. The typical clinical workflow includes registration and verification of clinical indications, review of prior imaging if available, targeted positioning and imaging of both breasts with diagnostic views, use of computer-aided detection (CAD) if performed, preliminary image review by the technologist, and final interpretation by a radiologist who documents findings, comparison to prior exams, and recommended follow-up (additional imaging, ultrasound, or biopsy). The service is commonly provided in an outpatient radiology department or an ambulatory imaging center equipped for mammography. Professional and technical components may be billed separately using modifier 26 for the professional component and modifier TC for the technical component when applicable.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component |