Name: Bilateral Mammogram

Medical Specialty: Obstetrics / Gynecology 

Description: Bilateral Mammogram (abnormal), additional views requested
(Medical Transcription Sample Report) 

EXAM: Mammographic screening FFDM

HISTORY: 40-year-old female who is on oral contraceptive pills. She has no present symptomatic complaints. No prior history of breast surgery nor family history of breast CA.

TECHNIQUE: Standard CC and MLO views of the breasts.

COMPARISON: This is the patient’s baseline study.

FINDINGS: The breasts are composed of moderately to significantly dense fibroglandular tissue. The overlying skin is unremarkable. 

There is a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.

There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.

There are no spiculated masses or architectural distortions.

IMPRESSION: Tiny cluster of calcifications at the 11:30 position of the right breast. Recommend additional views; spot magnification in the MLO and CC views of the right breast.

BIRADS Classification 0 – Incomplete 

MAMMOGRAPHY INFORMATION:
1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.
2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.
3. These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized. 

Scenario Summary (Coding Context)

• Patient: 40-year-old female

• Specialty: OB/GYN / Radiology

• Encounter Type: Screening bilateral mammogram

• Findings: Cluster of calcifications in right breast

• BI-RADS: 0 – Incomplete

• Outcome: Additional diagnostic views recommended, not yet performed

CPT / HCPCS PROCEDURE CODES

Code for THIS Encounter

77067 – Screening mammography, bilateral (2-view study of each breast), including CAD

Rationale:

• Exam is explicitly documented as screening mammography (FFDM)

• Patient is asymptomatic

• No prior breast cancer, surgery, or family history

• Bilateral CC and MLO views performed

• CAD software (iCAD Second Look) was used → included in code

• BI-RADS 0 does not change the screening CPT code for this visit

Codes NOT Assigned for This Encounter

• 77065 / 77066 (Diagnostic mammography)
  Not coded yet — additional views were recommended but not performed

• Add-on spot magnification codes
  Not separately reportable; bundled into diagnostic mammography when performed

ICD-10-CM DIAGNOSIS CODES

Primary Diagnosis (Screening Visit)

Z12.31 – Encounter for screening mammogram for malignant neoplasm of breast

Rationale:

• Patient presents without symptoms

• Exam purpose was screening

• Findings discovered during screening do not replace the screening diagnosis for this visit

Diagnosis Codes NOT Used Yet

• R92.1 (Mammographic microcalcification)
  Not reported until diagnostic imaging is performed

• N63 (Breast lump)
  No palpable mass

• Z80.3 (Family history of breast cancer)
  Explicitly denied in documentation

BI-RADS 0 Coding Guidance (Important)

BI-RADS 0 = Incomplete

• Indicates need for additional imaging

• Does NOT convert the screening mammogram into a diagnostic exam

• Screening CPT remains valid for this encounter

Coding for the FOLLOW-UP Visit (When Additional Views Are Performed)

These codes are NOT billed today, but are included for coder clarity.

CPT

77065 – Diagnostic mammography, unilateral (right breast), including CAD

Rationale:

• Additional spot magnification CC and MLO views

• Imaging limited to right breast

• CAD included

ICD-10-CM

R92.1 – Mammographic microcalcification

Rationale:

• Used once imaging is diagnostic

• Reflects the calcifications identified on screening

Final Coding Summary

Key Coding Takeaways

• Screening stays screening, even with abnormal findings

• BI-RADS 0 ≠ diagnostic exam

• Do not assign abnormal findings diagnosis codes until diagnostic imaging occurs

• CAD is included, not separately billable

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