Wiki Radiology Coding

mfournier

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Hello Everyone:

I just have a quick question, I hope. I was asked to help code for some radiology services 77062/TC, 77065/TC 76642/TC (and other codes as well)
To come up with a diagnosis code do you pull it from the radiology report? if so do you code from the Indication, Findings or Impression. Listed is an example of one report. This one seems to be not too complicated. But what happens when the findings are different then the impression? Sorry I hope I'm making sense.

Any information would be greatly appreciated.

Thank you :)

LEFT BREAST LIMITED ULTRASOUND: 12/5/2022

INDICATION: cb dx lt mm/ us lt br focal asym

COMPARISON: No priors listed at this institution.

FINDINGS:

A targeted left breast ultrasound was performed at the 3:00 position the retroareolar breast tissue. This
demonstrates an anechoic 4 x 5 x 3 mm probable cyst. There is an adjacent 5 x 4 x 2 mm probable cyst.
Either of these may account for the mammographic finding.

IMPRESSION:

There are two probable cysts within the retroareolar lateral left breast tissue which may account for the
mammographic finding. A six month follow-up left breast mammogram and ultrasound is recommended to
demonstrate stability.



BIRADS 3...Probably Benign Findings - Suggest Follow-Up
 
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