Breast Screening and Imaging Appropriateness Criteria
On this page you will find best practice breast screening and imaging appropriateness criteria for the following:
- Screening Mammography
- Diagnostic Mammography
- Digital Breast Tomosynthesis (DBT)
- Breast Ultrasound
- Breast MRI
- Fast Breast MRI
- Image-guided Breast Biopsy
- Ultrasound-guided Cyst Aspiration
- Breast Imaging FAQs
Screening mammography
Screening mammography should be performed annually starting at age 40 for all women. Patients do not need an order or referral from their doctor to schedule a screening mammogram. Patients can select date, time, and location for screening mammograms online through MyChart and results are released automatically to MyChart.
| Screening Codes | IMG Code | CPT Code | |
|---|---|---|---|
| Bilateral screening mammogram with tomosynthesis | IMG8074 | 77063, 77067 |
For screening mammograms, please use ICD10 code Z12.31
For patients who have had a unilateral mastectomy for breast cancer and therefore require unilateral breast cancer screening, use IMG8078 (right) or IMG8079 (left).
Diagnostic mammography
Indications for diagnostic mammography include:
- Breast symptoms (i.e. palpable breast lump, focal breast pain, suspicious nipple discharge)
- Callback from screening mammography
- Short term follow up for a finding seen on a prior diagnostic mammogram
- Annual surveillance in patients with recent history of breast cancer
A diagnostic mammography appointment may include additional mammographic views and/or a breast ultrasound. Patients will receive their results at the end of the appointment.
| Diagnostic Mammogram Codes | IMG Code | CPT Code |
|---|---|---|
| Bilateral diagnostic mammogram with tomosynthesis | IMG601 | 77062, 77066, G0279 |
| Right diagnostic mammogram with tomosynthesis | IMG602 | 77061, 77065, G0279 |
| Left diagnostic mammogram with tomosynthesis | IMG603 | 77061, 77065, G0279 |
If a patient is over 30 and has not had a bilateral mammogram in over six months, please order a bilateral exam even if symptoms are unilateral.
Digital breast tomosynthesis (DBT)
Digital breast tomosynthesis (DBT) is a quasi-3D mammogram which allows radiologists to see more details of the breast tissue. With DBT, breast radiologists can find more breast cancers and call back fewer patients for additional imaging. DBT is beneficial to all women but is most beneficial in women with dense breast tissue. Both screening mammography and diagnostic mammography can be performed with DBT.
Breast ultrasound
Breast ultrasound is typically used in combination with mammography. Breast ultrasound is used as a first imaging modality in young patients (<30 years) with breast symptoms.
Screening breast ultrasound can be used as a supplemental screening modality with mammography. This slightly increases cancer detection, but also a high false positive rate. Screening ultrasound is recommended for high risk women who are unable to have breast MRI.
| Diagnostic Ultrasound Codes | IMG Code | CPT Code |
|---|---|---|
| Bilateral limited breast ultrasound | IMG581 | 76642 |
| Left limited breast ultrasound | IMG582 | 76642 |
| Right limited breast ultrasound | IMG583 | 76642 |
| Axilla ultrasound | IMG8010 | 76882 |
Breast MRI
Indications for breast MRI include
- High risk screening
- Extent of disease evaluation in newly diagnosed breast cancer
- Evaluate response to neoadjuvant chemotherapy
- Suspected occult breast cancer (for example, patients with axillary metastases)
- Pathologic nipple discharge without abnormality on mammogram/ultrasound
- Silicone implant integrity evaluation
High risk patients include women with a BRCA gene mutation and their untested first degree relatives, women with chest irradiation between 10 to 30 years of age, and women with >20% lifetime risk of breast cancer.
Patients with silicone implants should be screened for silent implant rupture at 5-6 years after surgery and then every 2-3 years afterwards.
| Breast MRI | IMG Code | CPT Code |
|---|---|---|
| Bilateral breast MRI with and without contrast | IMG1143 | 77049, C8908 |
| Bilateral breast MRI without contrast Only for silicone implant evaluation | IMG1144 | 77047 |
Fast Breast MRI
Fast Breast MRI (Abbreviated Breast MRI) indications include
- Dense breasts
- Average or intermediate risk of breast cancer
The Fast Breast MRI exam is an additional screening exam to be conducted along with screening mammograms. This exam, which takes 10 minutes, is usually 10 minutes when compared to the 30-minute-long High Risk MRI exam. Patients with a higher lifetime risk of breast cancer may be better suited for the High Risk Screening breast MRI exam. Fast Breast MRI is not covered by insurance and is currently only offered at the Bethesda Johns Hopkins Medical Imaging location.
| Screening Codes | IMG Code | CPT Code |
|---|---|---|
| Fast Breast MRI | IMG4464 | 77049, C8908 |
Image guided breast biopsies
When a suspicious finding is seen on breast imaging, a biopsy should be performed. The biopsy is performed using the modality that best visualizes the finding (mammogram, ultrasound, or MRI). All biopsies are performed using a local anesthetic. Breast biopsies are very safe. Prior to a breast biopsy, the radiologist will explain the procedure in detail to the patient and answer any questions.
| Breast Procedure Codes | IMG Code | CPT Code |
|---|---|---|
| Breast ultrasound-guided biopsy | IMG1069 | 19083 |
| Breast stereotactic/tomosynthesis-guided biopsy | IMG614 | 19081 |
| Breast MRI-guided biopsy | IMG3084 | 19085 |
Ultrasound guided cyst aspiration
Most breast cysts can be safely assessed as benign and do not require an aspiration. However, if a patient has a symptomatic breast cyst or a suspected breast abscess, an ultrasound guided aspiration can be performed. This can be both therapeutic and diagnostic.
| Breast Procedure Codes | IMG Code | CPT Code |
|---|---|---|
| Breast ultrasound guided cyst aspiration | IMG8000 | 19000, 76942 |
| Breast ultrasound guided abscess drainage | IMG8009 | 19020, 76942 |
Frequently asked questions
Q: What should I order for my patient who presents with a palpable breast lump?
A: Diagnostic mammogram and ultrasound.
Q: My patient feels a breast lump. How likely is this to be breast cancer?
A: Most palpable breast lumps are benign. However, a new palpable mass can be a presenting symptom of breast cancer. All new palpable breast lumps should be further evaluated with diagnostic mammogram and ultrasound.
Q: What should I order for my patient with bilateral cyclical diffuse breast pain?
A: Patients with bilateral cyclical diffuse breast pain typically do not require nonroutine breast imaging.
Q: At what age should I start ordering screening mammograms for my patients who have average lifetime risk of breast cancer?
A: Age 40. The American College of Radiology, Society of Breast Imaging, and USPSTF all agree that mammographic screening for average risk women should begin at age 40.
Q: Should I order screening mammograms with digital breast tomosynthesis?
A: Yes. Screening mammograms performed with digital breast tomosynthesis allow radiologists to find more breast cancers and call back fewer patients.
Q: My patient wants to have screening ultrasound instead of screening mammogram. Is that okay?
A: No. Mammography is the only screening modality proven to decrease breast cancer mortality. We recommend annual screening mammography for all women starting at the age of 40. Screening ultrasound can be used as a supplement screening modality in some subsets of patients.
Q: My patient has had silicone implants for 10 years and suddenly developed a contour irregularity on one side. What test should I order?
A: Breast MRI without contrast.
Q: My patient had a suspicious finding on a recent mammogram and a biopsy was recommended. How do I know which kind of biopsy to order?
A: The radiology report will specifically state which type of biopsy is being recommended. Options are ultrasound-guided, stereotactic/tomosynthesis-guided, and MRI-guided.
This guide is for informational purposes only and does not constitute medical or legal advice, and is not intended for use in the diagnosis or treatment of individual conditions. The guide is not comprehensive and is provided as an example only, and should not be used as a substitute for the exercise of professional judgment, including but not limited to, in connection with any billing, imaging, CPT or other orders or healthcare claims related matter. The mention of any test, protocol, product, service, organization, activity, or therapy should not be construed as an endorsement by Johns Hopkins or its affiliates. This information is provided without representations or warranties of any kind, express or implied, all of which are disclaimed. Johns Hopkins and its affiliates assume no responsibility for any injury or damage to persons or property, delays or loss of revenue/income arising out of or related to the guide.