Find information on Breast Exam, Mammogram, and Clinical Breast Examination (CBE) documentation and medical coding. Learn about healthcare guidelines for performing and documenting breast exams, including proper terminology for clinical findings. This resource provides details on relevant medical codes for accurate billing and reimbursement related to mammograms and CBEs. Improve your clinical documentation practices for breast health assessments.
Also known as
Encounter for screening mammogram
Routine mammogram for breast cancer screening.
Encounter for other screening mammogram
Other specified screening mammograms.
Encounter for other examination
General health exam, including breast exam if performed.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the exam for screening?
Yes
Is there a personal history of breast cancer?
No
Is there a sign/symptom or abnormal finding?
When to use each related code
| Description |
|---|
| Breast exam for screening or diagnosis of breast conditions. |
| Diagnostic imaging of the breast to detect abnormalities. |
| Physical examination of the breasts by a healthcare professional. |
Missing or incorrect laterality (right, left, bilateral) can impact reimbursement and quality metrics for breast exams/mammograms.
Incorrectly coding a screening mammogram as diagnostic or vice versa leads to claim denials and inaccurate reporting.
Separate coding of components of a complete breast exam or mammogram when a comprehensive code exists leads to overbilling.
Q: What are the key differences in breast exam guidelines for average-risk women versus high-risk women, considering factors like age, family history, and genetic predisposition?
A: Breast exam guidelines vary significantly for average-risk versus high-risk women. For average-risk women, the American Cancer Society recommends starting yearly mammograms at age 45, with the option to start at 40. Clinical breast examinations (CBEs) can be performed every 1-3 years for women in their 20s and 30s, and annually for women 40 and older. However, for high-risk women, which includes those with strong family history of breast cancer, known BRCA mutations, or a history of chest radiation therapy, more intensive screening is often recommended. This can involve starting annual mammograms and breast MRIs at an earlier age, sometimes as early as 30, and potentially more frequent CBEs. Individualized risk assessment is crucial for tailoring screening strategies. Explore how our risk assessment tool can help personalize breast cancer screening for your patients.
Q: How can I effectively communicate breast exam results, including mammogram and clinical breast exam findings, to a patient in a clear, empathetic, and understandable manner while addressing potential anxiety?
A: Communicating breast exam results requires clarity, empathy, and a sensitivity to patient anxiety. Begin by explaining the findings in plain language, avoiding technical jargon. Clearly differentiate between normal findings, benign abnormalities, and areas requiring further investigation. When discussing abnormal findings, such as a suspicious mass or calcification seen on a mammogram, emphasize the importance of additional testing, such as a diagnostic mammogram, ultrasound, or biopsy, to obtain a definitive diagnosis. Reassure the patient that the majority of abnormalities found are benign. Provide educational resources and address any questions or concerns the patient may have. Consider implementing a standardized communication protocol to ensure consistency and improve patient understanding. Learn more about effective communication strategies for delivering difficult medical news.
Patient presented for a breast exam due to concerns regarding breast health. The patient's chief complaint included (patient reported symptom, e.g., breast pain, palpable lump, nipple discharge). A comprehensive clinical breast examination (CBE) was performed, evaluating both breasts and axillary lymph nodes. Mammogram history was reviewed (e.g., date of last mammogram, results). Breast density was assessed (e.g., fatty, scattered fibroglandular, heterogeneously dense, extremely dense) and documented. Findings of the CBE included (e.g., no palpable masses, well-defined mobile mass, skin changes, nipple inversion). Patient's personal and family history of breast cancer was assessed, including BRCA status if known. Assessment includes (e.g., fibrocystic breast changes, breast mass, suspected breast cancer). Plan includes (e.g., routine screening mammogram, diagnostic mammogram with ultrasound, referral to breast surgeon, genetic counseling). Patient education provided on breast self-awareness, early detection, and follow-up recommendations. ICD-10 code (e.g., N73.4, R92.0) and CPT code (e.g., 99213, G0101) assigned based on evaluation and management services provided. Medical necessity for services documented.