Dx mammo incl cad uni
CPT code 77065 is for a diagnostic mammogram on one breast that includes computer-aided detection (CAD) to help radiologists identify abnormalities. Unlike screening mammograms, this is ordered when there's already a symptom or concern that needs investigation.
This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
NCCI bundling edits
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Billing tips
Always append RT or LT modifier to indicate which breast was imaged
Impact: Prevents automatic denials and claim rejections; laterality modifiers are mandatory for Medicare and most commercial payers as of 2015
Document medical necessity with specific clinical indication beyond 'abnormal screening'
Impact: Increases first-pass approval rate by 35-40%; must include specific finding that prompted diagnostic exam (e.g., 'palpable 2cm mass at 3 o'clock position')
Do not separately bill CAD (77051/77052) as it is included in 77065
Impact: Prevents denials for unbundling and potential fraud allegations; CAD is integral to 77065 and billing separately violates CCI edits
When converting from screening to diagnostic same day, use modifier GG on the diagnostic code
Impact: Ensures payment for both services; without GG modifier, diagnostic claim may deny as duplicate with screening code already processed
Verify facility MQSA certification is current before billing
Impact: Expired MQSA certification results in 100% claim denial with no appeal option; certification must be displayed and valid on date of service
Link appropriate ICD-10 code that supports diagnostic (not screening) medical necessity
Impact: Using screening Z-codes (Z12.31) instead of diagnostic codes causes automatic denials; use symptom codes (R92.8, N63.xx) or findings codes to support diagnostic indication
Common denials
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