Find information on routine mammogram diagnosis, including clinical documentation requirements, medical coding guidelines (ICD-10, CPT), and healthcare best practices for screening mammography. Learn about BIRADS classification, diagnostic imaging procedures, and preventative breast health recommendations for asymptomatic patients. This resource provides essential details for healthcare professionals involved in breast cancer screening and early detection.
Also known as
Encounter for screening mammogram for malignant neoplasm of breast
Routine mammogram for breast cancer screening.
Encounter for other screening mammogram
Routine mammogram for screening purposes, not specifically for breast cancer.
Abnormal findings on diagnostic imaging of breast
Used if the mammogram reveals abnormal findings requiring further investigation.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the mammogram for diagnostic purposes?
Yes
Do NOT code as routine. See diagnostic mammogram guidelines.
No
Is there a personal history of breast cancer?
When to use each related code
| Description |
|---|
| Routine screening mammogram |
| Diagnostic mammogram |
| Breast ultrasound |
Missing or incorrect laterality (right, left, bilateral) can lead to claim denials or inaccurate reporting for routine mammogram screenings.
Miscoding a diagnostic mammogram as a screening mammogram or vice versa can impact reimbursement and quality metrics.
Incorrect or missing modifiers (e.g., for screening, diagnostic, or personal history) can affect payment and compliance with medical coding guidelines.
Routine screening mammogram performed on (Date) for (Patient Name), a (Age)-year-old female, with no significant breast complaints. Patient reports menarche at age (Age), (Number) pregnancies, (Number) live births, and menopause status (Premenopausal, Perimenopausal, Postmenopausal, or Surgical Menopause at age if applicable). Patient denies personal history of breast cancer, breast biopsies, or breast augmentation. Family history of breast cancer includes (Maternal/Paternal) (Relationship to patient if positive) diagnosed with breast cancer at age (Age), if applicable. Patient takes (Medications) and has no known drug allergies. Physical examination of the breasts reveals no palpable masses, skin changes, or nipple discharge. Mammogram imaging interpretation: (BIRADS classification, e.g., BIRADS 1 Negative). Breasts are symmetrical and dense. No suspicious masses, calcifications, or architectural distortions identified. Lymph nodes are not visualized. Impression: Negative screening mammogram. Recommendations: Continue routine screening mammography as per established guidelines (specify frequency, e.g., annually). Patient education provided regarding breast self-awareness and the importance of follow-up. Scheduled next routine mammogram in (Timeframe, e.g., one year). ICD-10 code: Z12.31 (Encounter for screening mammogram for malignant neoplasm of breast).