Oncology & Hematology Coding Alert

Question: A 63-year-old patient presented for a diagnostic mammography exam with complaints of a lump in her left breast. Our in-house radiologist performed the diagnostic mammography, but due to the patient’s dense breasts, the provider had difficulty evaluating the images. The radiologist received a new order and performed a unilateral breast magnetic resonance imaging (MRI) exam without contrast and then with contrast. After interpreting the images and writing their report, the radiologist issued their findings as an abnormal lump in the lower outer quadrant of the patient’s left breast.

How do I report this encounter?

Montana Subscriber

Answer: You’ll assign two CPT^® codes and two ICD-10-CM codes to report this encounter. Starting with the diagnostic mammography, you’ll assign 77065 (Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral) with modifier LT (Left side) appended to specify which breast was imaged. You’ll then assign a code from R92.3- (Mammographic density found on imaging of breast) based on the density level with 6th digit “2” to indicate left breast. If the density level is not documented, you might consider using R92.30 (Dense breasts, unspecified). Remember to also assign, R92.2 (Inconclusive mammogram) per the instructional note under R92.3-.

Next, you’ll turn your attention to the breast MRI exam. The radiologist performed the MRI without contrast, then administered contrast and captured additional images, so you’ll assign 77048 (Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral), appending modifier LT to the code as well.

Finally, you’ll assign N63.23 (Unspecified lump in the left breast, lower outer quadrant) to report the radiologist’s findings of an abnormal lump in the left breast’s lower outer quadrant.