Does G0279 require prior authorization?

No, G0279 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

What is the Medicare reimbursement rate for G0279?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.59.

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`G0279`, Diagnostic digital breast tomosynthesis, unilateral or bilateral (list

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Medicare Pricing

Work RVU

0.59

Facility

N/A

Non-Facility

N/A

Documentation Required

Documentation supporting services must be available to Medicare upon request.
The medical record must contain the ordering provider's assessment related to the patient's complaint, relevant medical history, and results of pertinent tests/procedures.

All services ordered or rendered must be signed and dated; signed and dated office visit records or operative reports must be in the record.

A clear clinical indication for diagnostic mammogram, breast sonogram, breast MRI, or ductogram must be documented in the medical record and in the referral/order.

A written referral is required for a diagnostic mammogram except when the diagnostic study was initially performed as a screening mammogram that prompted additional views.

The medical record must include a formal written report describing all views completed that states the reason for the test, a description of the test, interpretation and results, and the name of the physician to whom the report is being sent.

Key Coverage Criteria

Diagnostic mammography, breast sonography (echography), breast MRI, and ductography are covered when a clear clinical indication for the test is documented in the medical record and in the referral/order.
A diagnostic mammogram performed after an initial screening mammogram (conversion from screening to diagnostic) is allowable when the screening abnormality prompting additional views is documented in the record.
When digital breast tomosynthesis is the only imaging guidance used for a percutaneous core needle breast biopsy, bill CPT 19499 (Unlisted procedure, breast) and document the procedure name in the claim comments/narrative.
When tomosynthesis-only guidance is used to place a breast localization device (without biopsy), bill CPT 19499 with a clear description in the comments/narrative for Part A and Part B claims.
If a percutaneous breast biopsy is performed using both stereotactic and tomosynthesis imaging guidance, bill CPT 19081 for the first lesion (stereotactic guidance).
If more than one lesion is biopsied with tomosynthesis-only guidance on the same date of service, code an additional 19499 with modifier -59 for additional lesion(s) on the same breast, or use modifier -50 to indicate a bilateral procedure for lesions on the opposite breast.

8 Active Policies

CGS-J15-L33950, Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

J15

CGS-J18-L33950, Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

J18

ANTHEM-SURG.00045, Extracorporeal Shock Wave Therapy

A56448, Billing and Coding: Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

A57848, Billing and Coding: Tomosynthesis-Guided Breast Biopsy

A58559, Billing and Coding: Independent Diagnostic Testing Facilities (IDTF)

AETNA-CPB-0269, Breast Biopsy Procedures

HUMANA-BREAST-IMAGING-MA, Breast Imaging

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G0279, Diagnostic digital breast tomosynthesis, unilateral or bilateral (list