CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Mammography Screening Billing and Reimbursement Guideline

Guideline governing billing, coding, and reimbursement practices for screening and diagnostic mammography claims submitted to Neighborhood Health Plan of Rhode Island; applies to providers submitting CMS-1500 and UB-92 claims and impacts coding/modifier use for payment.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMammography Screening Billing and Reimbursement Guideline

Policy CodePolicy N/A

Change TypeFormat change and minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionWhen both screening and diagnostic mammography are performed the same day, attach modifier GG to the diagnostic mammography claim.

SourceLink

POLICY UPDATE CHANGES

Format change and minor edits were made on 9/1/2013.

2primary billable screening diagnosis codes listed

6key coding and modifier rules enumerated

2CAD procedure codes listed separately

2claim form types covered

Mammography Billing Requirements

Mammography billing requirements

Coverage direction and billing requirements

ALL of the following

Bill primary screening diagnosis codes V76.11 or V76.12 for screening mammography claims.
When submitting both a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier GG to the diagnostic mammography.
List procedure code 77051 (CAD for diagnostic mammography) separately in addition to the primary diagnostic procedure code (77055, 77056, G0204, G0206).
List procedure code 77052 (CAD for screening mammography) separately in addition to the primary screening procedure code (77057, G0202).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMammography Screening Billing and Reimbursement Guideline

Policy CodePolicy N/A

Change TypeFormat change and minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionWhen both screening and diagnostic mammography are performed the same day, attach modifier GG to the diagnostic mammography claim.

SourceLink

On This Page

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Codes, Modifiers, and Component Billing

Covered CPT CodesCPTCovered

77051	CAD for diagnostic mammography (list separately in addition to primary diagnostic procedure)
77052	CAD for screening mammography (list separately in addition to primary screening procedure)
77055	Diagnostic mammography, unilateral
77056	Diagnostic mammography, bilateral
77057	Screening mammography, bilateral
G0202	Screening mammography, bilateral (digital or film)
G0204	Diagnostic mammography, unilateral (digital or film)
G0206	Diagnostic mammography, bilateral (digital or film)
V76.11	Special screening for malignant neoplasm, screening mammogram for high-risk patients
V76.12	Special screening for malignant neoplasm, other screening mammogram

Modifier use when billing screening and diagnostic mammography same day - GG

RuleAttach modifier GG to the diagnostic mammography when both screening and diagnostic mammography are submitted for the same patient on the same day.

ApplicabilityApplies when both screening and diagnostic mammography are billed for the same patient on the same day.

Claim formsThis guideline applies to both CMS-1500 and UB-92 claim submissions.

Technical vs professional component billing - TC / 26

Technical componentUse modifier TC to bill the technical component only.

Professional componentUse modifier 26 to bill the professional component only.

Global feeOmit modifiers when billing a global fee (no modifier needed).

Modifier positioning when multiple modifiers required

Order of modifiersPlace the mammography modifier in position 1 when more than one modifier is necessary.

Second modifier examplePlace the other modifier (e.g., HPSA) in position 2.

When to useUse multiple modifiers only when more than one modifier is necessary for the service billed.

Administrative and Prior Authorization Notes

Prior Authorization

Prior Authorization / Administrative Note

No prior authorization is required for screening or diagnostic mammography. Providers must follow coding and claim submission rules to avoid denials: billable primary diagnosis codes for screening mammography are V76.11 (screening mammogram for high‑risk patients) and V76.12 (other screening mammogram). When both screening and diagnostic mammography are performed the same day, append modifier GG to the diagnostic mammography. Report computer‑aided detection codes separately: 77051 with diagnostic mammography (77055, 77056, G0204, G0206) and 77052 with screening mammography (77057, G0202). Use modifier TC for technical component only and modifier 26 for professional component only; no modifier is needed when billing a global fee. If multiple modifiers are required, place the mammography modifier in position 1 and the other modifier in position 2. These billing rules apply to both CMS‑1500 and UB‑92 claim submissions. Refer to Neighborhood Health Plan of Rhode Island's provider website for product‑specific provisions. This guideline does not guarantee reimbursement; plan coverage, eligibility, and claim‑edits may affect payment.

Billable screening diagnosis codes: V76.11, V76.12
Append modifier GG to diagnostic mammography when screening and diagnostic performed same day
Report 77051 with diagnostic mammography (77055, 77056, G0204, G0206)
Report 77052 with screening mammography (77057, G0202)
Use modifier TC = technical component only; 26 = professional component only; no modifier for global fee
If multiple modifiers needed, mammography modifier = position 1, other modifier = position 2
Applies to CMS‑1500 and UB‑92 claim submissions

Definitions and Modifier Glossary

CAD — Computer aided detection (CAD)

DefinitionComputer aided detection (CAD): computer algorithm analysis of digital image data for lesion detection with further physician review for interpretation.

Diagnostic CAD codeCPT 77051 — CAD for diagnostic mammography; list separately in addition to primary diagnostic procedure codes (77055, 77056, G0204, G0206).

Screening CAD codeCPT 77052 — CAD for screening mammography; list separately in addition to primary screening procedure codes (77057, G0202).

TC / 26 — Modifiers TC and 26

Modifier TCUse modifier TC to bill the technical component only.

Modifier 26Use modifier 26 to bill the professional component only.

Global billingWhen billing a global fee, no modifier is needed.

GG — Modifier GG

Purpose of GGAttach modifier GG to the diagnostic mammography when both screening and diagnostic mammography are submitted for the same patient on the same day.

Use caseUsed specifically to distinguish the diagnostic mammogram when a screening mammogram is also billed the same day.

Claim formsGuideline noting GG use applies to CMS-1500 and UB-92 claim submissions.