Find information on mammogram screening, including CPT codes, ICD-10 codes, clinical documentation requirements, and healthcare guidelines. Learn about breast cancer screening, diagnostic mammography, screening mammography, and the importance of early detection. This resource provides details on medical coding for mammograms, radiology coding, and best practices for accurate clinical documentation related to breast imaging and women's health.
Also known as
Encounter for screening mammogram
Routine mammogram for breast cancer screening.
Special screening for malignant neoplasm of breast
Screening for breast cancer due to high risk factors.
Special screening examination for other specified diseases
Screening exam related to personal/family history of breast disease (not cancer).
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the mammogram for diagnostic purposes?
Yes
Do NOT code as screening. Use appropriate diagnostic code (e.g., R92.2, N64.89).
No
Is there a personal history of breast cancer?
When to use each related code
| Description |
|---|
| Mammogram screening |
| Diagnostic mammogram |
| Breast ultrasound |
Missing laterality (right, left, bilateral) for mammogram screening can lead to claim denials and inaccurate data reporting.
Using a diagnostic code instead of a screening code (e.g., Z12.31) for asymptomatic patients leads to incorrect billing and compliance issues.
If screening reveals abnormality requiring diagnostic mammogram, lacking an Advanced Beneficiary Notice (ABN) can create financial liability for the patient.
Patient presents for routine screening mammogram. The patient reports no breast complaints, pain, nipple discharge, or skin changes. No palpable masses or lymphadenopathy were noted on clinical breast exam. Personal history is negative for breast cancer. Family history is non-contributory for breast cancer. The patient is not currently taking any medications. Menarche age was 13. Patient is gravida 0, para 0. Mammogram performed today was categorized as BI-RADS 1 (negative). Breast tissue is normal. No masses, architectural distortion, or suspicious calcifications are identified. Impression: Normal screening mammogram. Recommend routine screening mammogram in one year. Patient education provided regarding breast self-awareness and the importance of regular screening mammograms. Patient verbalized understanding.