Internal Medicine Coding Alert
Should You Add Breast Diagnostic to E/M?
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Question: My physician saw a patient for several problems, and while in the office, she told my physician she found a lump in her breast. My physician performed a breast exam. Is there a separate code for this in addition to the E/M? North Carolina Subscriber Answer: In short, no. Because your physician performed a diagnostic exam, not a screening, do not use G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). Report only an office visit code (99201-99215, Office or other outpatient visit ...). When determining the appropriate level of E/M service of the visit, consider the breast exam part of the office visits exam and possibly part of its medical decision making.
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