J863 – Scintimammography
OHIP Cardio-Thoracic Surgery Code — NUCLEAR MEDICINE - IN VIVO · Schedule of Benefits
Scintimammography is a nuclear medicine imaging procedure for unilateral or bilateral breast assessment. According to , the claim for the technical component is submitted using the fee schedule code with the suffix B and the claim for the professional component is submitted using the fee schedule code with a suffix C. The technical component fee is $119.35 and the professional component is $45.55. This service is not eligible for payment unless at least one of the following conditions is met: - The patient has a dense breast(s) and one or both of the following risk factors: - a first degree relative with breast cancer diagnosed prior to age 50; or - a first degree relative with breast cancer diagnosed over age 50 and patient is within 5 years of the age when the relative was diagnosed with breast cancer. - Architectural distortion of the breasts due to prior breast surgery, radiotherapy, chemotherapy or the presence of breast prosthesis rendering mammography interpretation difficult. - Malignant breast lesion when mammography is unable to exclude multifocal disease. - Solitary lesion identified on mammography of greater than 1 cm.
When to Use
- Use J863 when a patient has a solitary mammographic lesion greater than 1 cm that requires further characterization to rule out malignancy.
- Use J863 for patients with architectural distortion from prior breast surgery or radiotherapy where standard mammography interpretation is compromised.
- Use J863 to evaluate multifocal disease in patients with a confirmed malignant breast lesion where mammography results are inconclusive.
Common Pitfalls
- Submitting the claim without the mandatory B or C suffix will result in an automatic rejection as the system requires the split technical and professional component billing.
- Billing J863 for patients who do not meet the specific >75% fibroglandular tissue density threshold or the strict family history criteria will trigger an audit recovery.
- Attempting to bill the technical component (J863B) for an inpatient or a patient admitted within 24 hours of the procedure violates the GP11 payment adjustment rules.
Billing Tips
- Ensure the referring physician's written request explicitly documents the specific clinical condition from the approved list to support the medical necessity of the scan.
- Always verify the patient's mammography report confirms the >75% density or specific lesion size before billing, as these are the primary audit triggers for this code.
Effective: April 1, 2025
B. Nuclear Medicine - IN VIVO
NUCLEAR MEDICINE - IN VIVO
Diagnostic
Nuclear Medicine - IN VIVO
A copy of the written request for the consultation, signed by the referring physician, nurse practitioner or dental surgeon must be kept in the consulting physician’s medical record.
For the purpose of this provision, 'dense breast(s)' means (a) breast(s) occupied by over 75% fibroglandular tissue as noted on mammography.
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