# breast exam



## TCarrasco

Is a routine breast exam part of an office visit? The situation that came up was a pt came in for a diabetic follow up then mentioned to the provider that she felt a lump in her breast. The provider then did the breast exam on the pt.Is there a seperate cpt code for this or would it be part of the visit?
Any info would be greatly appreciated!!

Thanks!


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## amjordan

There is no separate CPT code for a Breast Exam.  However, the provider would use the additional history, breast exam and any additional medical decision making to determine which level of E/M he is going to bill.  

Now, there is a HCPCS code S0613 Annual gynecological examination; clinical breast examination without pelvic examination.  Not all carriers recognize or even use this code.


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## Karolina

If the patient felt a lump in the breast then it is likely not a routine breast exam. This needs to be documented and considered for the level of E/M as Angela already mentioned. Also make sure to include the proper ICD-9 code on your claim.


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## debherrera

In this case I would include this as part of the office visit.  Use dx code V76.10 for the breast exam.

If the provider completed a  gyn exam, then in that case you can bill a preventive plus exam.


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## andecin

I agree it is inclusive with the office visit.  I would code it as a breast mass/lump.  I would not use V76.10.


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## TCarrasco

Thanks for all the info!!! ;0)


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