Screening mammography is a cornerstone of preventive care, and primary care providers (PCPs) are often the clinicians who order these tests and counsel patients. But when it comes to billing, many practices wonder whether a PCP can submit claims using HCPCS code G0202 for screening mammograms. The short answer: in today’s billing environment, G0202 has been retired, and screening mammography coding and payment rules are primarily tied to CPT codes and Medicare policies – and a PCP may only bill the imaging code if the practice actually performs the mammogram and meets strict facility and regulatory requirements. Below, I explain what changed, what the rules are now, and provide practical guidance for PCPs and billing teams.
What G0202 Was – and why it matters
G0202 used to be the HCPCS Level II code used to report a bilateral screening mammogram (two views per breast), including computer-aided detection (CAD) when performed. That code guided how Medicare and some payers processed and paid screening mammography claims for many years. Understanding G0202’s historical role matters because legacy documentation, prior authorizations, and older payer policies can still reference the code.
Has G0202 been replaced? What to code now
CMS and payers moved to align mammography billing with CPT codes. G0202 was deleted effective January 1, 2018, and screening mammography reporting is handled with CPT-level codes (for example, 77067 for bilateral screening mammography including CAD when performed). Practices, coders, and billing staff should stop relying on G0202 for current claims and use the CPT equivalents required by CMS and most commercial payers.
Who actually bills for a screening mammogram?
Ordering provider vs. performing provider
It’s important to distinguish between the clinician who orders the test (often the PCP) and the entity that performs and bills for the imaging. In most situations:
- The PCP is the ordering provider and bills for the office visit (e.g., preventive visit or E/M service).
- The imaging center, hospital outpatient department, or radiology practice that performs the mammogram bills the mammography code (CPT 77067 or applicable code) and receives reimbursement for the imaging service.
PCPs do not get paid the imaging fee simply for ordering the mammogram. The imaging facility, which furnishes the equipment, technologists, and typically the interpreting radiologist, bills the mammography code. This division is standard in the industry and helps ensure that claims reflect who actually rendered the technical and/or professional components of the service.
When a PCP can bill for the mammogram
A PCP can bill the mammography code (previously G0202, now the CPT equivalent) only if the practice actually performs the screening mammogram and satisfies all regulatory, accreditation, and payer requirements. That generally means:
- The practice owns or operates the imaging equipment and provides the technical service.
- The facility is certified and accredited under the Mammography Quality Standards Act (MQSA) and any state requirements.
- Qualified personnel perform and interpret the study (interpreting radiologists must meet credentialing/qualification standards).
- The practice is enrolled with Medicare (or the payer) to bill for imaging services and has the appropriate place-of-service designation.
In short, billing requires rendering the service, not merely ordering it. If a PCP’s office lacks MQSA certification and the required infrastructure, the practice must refer the patient to an accredited facility to perform the mammogram. The MQSA and FDA set the federal accreditation and quality standards that mammography facilities must meet.
Medicare coverage rules and frequency (straight facts)
Medicare Part B covers screening and baseline mammograms under preventive benefits. Key points every PCP and billing staff should know:
- Medicare covers one baseline mammogram for women aged 35–39 (once in a lifetime).
- Medicare covers one screening mammogram every 12 months for women aged 40 and older.
- Screening and baseline mammograms are typically covered at no cost to the beneficiary (no Part B deductible or coinsurance) when the provider accepts assignment. Diagnostic mammograms (when there are signs or symptoms) are billed differently and may incur coinsurance after the deductible.
These frequency and coverage rules are enforced by Medicare and local Medicare Administrative Contractors; billing earlier than the allowed interval or misclassifying a diagnostic study as screening can trigger denials or audits.
Screening vs. diagnostic mammography – why classification matters
Whether a study is billed as “screening” or “diagnostic” depends on clinical indication and documentation:
- Screening mammogram: performed for asymptomatic patients as routine prevention.
- Diagnostic mammogram: performed when symptoms are present (e.g., palpable lump, nipple discharge, or abnormal finding on prior imaging) or when additional views are clinically necessary.
If an imaging center converts a scheduled screening study to diagnostic during the visit (because the radiologist needs extra views or the patient reports symptoms), the claim must be billed using diagnostic mammography codes. Clear documentation of symptoms and clinical findings is essential to support the billing classification.
Documentation and billing best practices
Good documentation is the backbone of correct billing and defensible claims. Make sure your practice’s workflows capture the following every time:
- Clinical indication: Is this screening or diagnostic? Document absence of symptoms for screening.
- Patient eligibility and date of last mammogram (to ensure spacing rules are met).
- Physician’s order for the mammogram (date and reason).
- If the practice performs the imaging: MQSA certificate, equipment details, and the name/license of the interpreting physician.
- If only interpreting services are provided, use appropriate modifiers (professional component -26) and document the interpretation and signature.
A short checklist approach in your chart template or referral form can reduce downstream denials: include the last mammogram date, symptom screening checkbox, and ordering clinician signature.
Common billing mistakes and how to avoid them
Although the underlying rules are straightforward, billing mistakes happen frequently. Watch for these common errors:
- Using deleted codes: Submitting G0202 for current Medicare claims will cause denials; use the CPT equivalents instead.
- Confusing screening and diagnostic claims: Always document symptoms (or lack thereof).
- Billing the mammogram when your clinic only ordered it: Only bill when you performed the technical and/or professional component.
- Frequency violations: Submitting a screening mammogram before the 12-month interval can prompt rejection.
Compliance risk and audit considerations
Improperly billing mammography services can lead to recoupments, Medicare audits, and potential penalties. Practices that decide to offer in-house mammography must be prepared for MQSA inspections, maintenance of equipment logs, credentialing of interpreting physicians, and robust record-keeping. Even ordering practices should maintain clear documentation of the referral and patient counseling to reduce exposure in audits. CMS guidance, Medicare transmittals, and payer local coverage determinations are the main references auditors use. Keep current copies and train the billing staff accordingly.
Practical recommendations for PCPs and practice managers
If you do NOT perform mammography in your office
- Refer patients to accredited imaging centers and document the referral.
- Bill the appropriate E/M visit code for counseling or preventive visits, but do not bill the imaging code.
- Consider building a preferred-provider relationship with local radiology centers to streamline scheduling and reduce patient friction.
If you ARE considering in-house mammography
- Perform a business case analysis: equipment cost, staffing, accreditation costs, and expected volume.
- Obtain MQSA accreditation and maintain all required quality tests, logs, and personnel credentials.
- Ensure your billing team is trained on CPT mammography codes, technical/professional component billing, and Medicare rules.
For billing teams
- Use current CPT codes (e.g., 77067 for screening) and check payer policies for tomosynthesis, CAD add-ons, and local coverage variations.
- Routinely audit mammography claims to catch miscoding or frequency errors early.
Short glossary (quick reference)
- G0202 – historical HCPCS code for bilateral screening mammography (deleted Jan 1, 2018).
- 77067 – CPT code commonly used now for bilateral screening mammography, including CAD when performed.
- MQSA – Mammography Quality Standards Act; federal program governing accreditation and quality for mammography facilities.
Final thoughts
Primary care physicians play an essential role in ensuring patients receive timely breast cancer screening, but billing for the imaging requires clarity about who actually rendered the service and adherence to current coding, payer, and federal regulations. G0202 is part of the historical record; for present-day claims, you should rely on current CPT coding (for example, 77067) and the Medicare and MQSA rules that govern where and how mammography is performed and billed. If your practice contemplates offering in-office mammography, plan carefully for accreditation, staffing, and compliance – otherwise continue to build efficient referral workflows that link your preventive care work to accredited imaging providers.