Please code the CPT and ICD-10-CM code for this report.
Name: Jane Doe
Reading Dr. Dr Smith
Jan 1, 2018–3:00 pm
Exam-Mammo Diag left
Procedure- Diagnostic Mammogram Unilateral with CAD
History- Diagnostic mammo ordered for palpable left breast lump
Technique Full field mammography was performed, including unilateral CC and MLO views. Computer aided detection was utilized as an aide in the exam
Comparison- Ultrasound images of the left breast dates 4/4/17
Findings- Left mammogram- there is a 8 mm oval well-circumscribed density mass in the upper outer quadrant.
Impression- Suspected cyst. Follow up with ultrasound.
I agree with the above findings- signed Dr Smith 4:00 pm Jan 1, 2018
**Note- this report is HIPAA compliant and does not contain any phi or real info.