Wiki Coding Abnormal Mammogram

[brendakstro]

I have a mammogram report that describes a nodule of 11*9 mm with obscured margins, in the impression says "Bi Rads O- Incomplete mammogram" with recommendation of US of breast. Should I code the breast nodule or BI-RADS 0 (R92.2)? thank you

 

[danachock]

Hi bcastro@donnamedicalclinic.com
Sorry, but there is not enough information to assist with proper coding guidance with your question. I am assuming you are coding the professional fees??
Would you simply please provide (non HIPAA information) for us to help you?
1) The diagnosis code or codes on why the mammogram was actually ordered.
2) The full interpretation of the radiologist's interpretation - the manner in which the interpretation is worded can completely change the coding scenario.
Thanks for listening,
Dana Chock, RHIT, CPC, CANPC, CHONC, CPMA, CPB
Coding Analyst (May 2018-present), Pathology & Laboratory Coder (Fall 2012-May 2018), Anesthesia Coder (April 2013-May 2018)

 

[RobynKing]

I am also interested in the BI-RADS coding. Should we or shouldn't we put those on the mammogram results. They are there for a reason I think. I found this while googling BI-RADS and coding them: The test results are scored in BI-RADS (Breast Imaging Reporting and Data System) categories, which range from category 1 (not cancer) to category 6 (high likelihood of cancer). A category 0 means more tests are needed. Mammogram reports also include four categories for breast density. Just about all the cases I code have density but it isn't put into the impression, only in the findings. We can only code from the Impression but the BI-RADS is always under the impression. Anything?