Please read the report below and code the CPT and the ICD-10-CM Code. Please keep in mind that these reports are designed to be as realistic as possible, but everything is HIPAA compliant so the information is not real.
*For the tomo, please use the HCPCS code.
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Procedure- Bilateral Diagnostic Mammogram with Tomo
History- Bilateral breast pain for 2 weeks
Technique- Full field mammography was performed. Bilateral breast tomosynthesis was preformed in the MLO and CC projections. CAD was used as an aid for interpreting this exam.
Comparison: Prior mammo from April 2017
Density- There are scattered fibroglandular densities
Findings: There is no suspicious mass, microcalcifications, or unexplained distortions.
Impression: No dominant mass or secondary signs of malignancy within either breast. Annual screenings recommended. BIRADS ASSESSMENT- (2) Benign findings.
Signed Dr. J.
