Coding Abnormal Mammogram

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I have a mammogram report that describes a nodule of 11*9 mm with obscured margins, in the impression says "Bi Rads O- Incomplete mammogram" with recommendation of US of breast. Should I code the breast nodule or BI-RADS 0 (R92.2)? thank you
 

danachock

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Hi bcastro@donnamedicalclinic.com
Sorry, but there is not enough information to assist with proper coding guidance with your question. I am assuming you are coding the professional fees??
Would you simply please provide (non HIPAA information) for us to help you?
1) The diagnosis code or codes on why the mammogram was actually ordered.
2) The full interpretation of the radiologist's interpretation - the manner in which the interpretation is worded can completely change the coding scenario.
Thanks for listening,
Dana Chock, RHIT, CPC, CANPC, CHONC, CPMA, CPB
Coding Analyst (May 2018-present), Pathology & Laboratory Coder (Fall 2012-May 2018), Anesthesia Coder (April 2013-May 2018)
 
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