Patient presents for further evaluation following an inconclusive mammogram.  The initial mammogram, performed on [date], demonstrated [specific finding, e.g., an area of architectural distortion, a focal asymmetry, or a cluster of microcalcifications] in the [location, e.g., right upper outer quadrant].  This finding was categorized as BIRADS 0 (Incomplete).  Patient denies any palpable breast lumps, nipple discharge, skin changes, or pain.  Patient's medical history includes [relevant medical history, e.g., nulliparity, family history of breast cancer, prior breast biopsies, hormone replacement therapy].  Physical examination reveals [findings, e.g., normal breast tissue, no palpable masses, no lymphadenopathy].  Given the inconclusive mammogram findings, additional imaging with diagnostic mammogram and targeted ultrasound is recommended to further characterize the area of concern and rule out malignancy.  Patient education was provided regarding the importance of follow-up imaging and the potential need for biopsy.  Risks and benefits of further diagnostic procedures were discussed, and the patient expressed understanding.  A follow-up appointment has been scheduled for [date].  Differential diagnoses include benign breast changes, fibrocystic breast disease, and breast cancer.  Medical coding considerations include ICD-10 code R92.8 (Abnormal findings on diagnostic imaging of breast) and CPT codes for diagnostic mammogram (77066, 77067) and breast ultrasound (76641, 76642), as appropriate.