X172 – Mammogram - unilateral (no signs or symptoms)
OHIP Laboratory Code — DIAGNOSTIC RADIOLOGY · Schedule of Benefits
A unilateral mammogram performed using dedicated equipment. This service is indicated when the sole reason for the request for a mammogram is for an individual with identified risk factors in accordance with clinical practice guidelines, and who has no signs or symptoms of breast disease. This service has a technical component (H) and a professional component (P). The claim for the technical component is submitted using the fee schedule code with suffix B (X172B) and the claim for the professional component is submitted using the fee schedule code with a suffix C (X172C), as per .
When to Use
- Use X172 for asymptomatic patients with a high-risk genetic predisposition (e.g., BRCA mutation) or a strong family history requiring surveillance mammography.
- Use X172 for patients requiring unilateral surveillance of a remaining breast following a mastectomy for breast cancer, provided no new signs or symptoms are present.
Common Pitfalls
- Billing X172 for patients presenting with palpable lumps, nipple discharge, or other breast symptoms, which instead requires diagnostic codes like X178.
- Submitting X172 without the required B (technical) and C (professional) suffixes, which will result in automatic claim rejection.
- Attempting to claim the technical component (X172B) for services performed on hospital in-patients or out-patients admitted within 24 hours, as this is strictly prohibited by OHIP payment rules.
Billing Tips
- Always ensure the referral indicates the specific risk factor (e.g., genetic mutation or high-risk screening program eligibility) to satisfy the 'no signs or symptoms' requirement.
- If a patient requires a second mammogram on the same day using a different modality, submit the additional service with a manual review indicator to avoid duplicate claim denials.
Effective: April 1, 2025
D. Diagnostic Radiology
DIAGNOSTIC RADIOLOGY
Diagnostic
Diagnostic Radiology
The physician submitting a claim for the technical component is responsible for the complete quality assurance process for all elements of the technical component of the service, including data acquisition, reporting, and record keeping. The physician must be able to demonstrate the above upon request by the MOH.
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