mkknowle
New
This is for Bilateral MRI of the breasts.
CLINICAL INDICATIONS: High-risk surveillance underway for a 43-year old woman with prior left breast carcinoma with breast reconstruction. There is a known lymph node lateral to the implant at approximately at the 2:30 position on the left. The patient indicates that there is some palpable fullness above the implant on the left.
CONCLUSION:
Right Breast: No malignant-appearing findings or interval changes of concern. MR BI-RADS category 2, benign.
Left Reconstructed Breast: Stable findings, with an intact implant and a known benign lymph node at the 2:30 position. No malignant-appearing findings in the area of the patient's concern or elsewhere. MR BI-RADS category 2, benign.
I was planning on using V10.3 (Personal history of malignant neoplasm; Breast) as the primary dx. Would I use 229.0 (Benign neoplasm of other and unspecified sites; Lymph nodes) as a 2ndary dx or is a 2ndary dx even necessary?
Thanks in advance for any help
,
CLINICAL INDICATIONS: High-risk surveillance underway for a 43-year old woman with prior left breast carcinoma with breast reconstruction. There is a known lymph node lateral to the implant at approximately at the 2:30 position on the left. The patient indicates that there is some palpable fullness above the implant on the left.
CONCLUSION:
Right Breast: No malignant-appearing findings or interval changes of concern. MR BI-RADS category 2, benign.
Left Reconstructed Breast: Stable findings, with an intact implant and a known benign lymph node at the 2:30 position. No malignant-appearing findings in the area of the patient's concern or elsewhere. MR BI-RADS category 2, benign.
I was planning on using V10.3 (Personal history of malignant neoplasm; Breast) as the primary dx. Would I use 229.0 (Benign neoplasm of other and unspecified sites; Lymph nodes) as a 2ndary dx or is a 2ndary dx even necessary?
Thanks in advance for any help
,