coding challenge

Coding Challenge 6

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.

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