Assign Appropriate Codes Explained for Students (Easy Guide)

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Original Question

Assign the appropriate codes for the following procedure(s). Include any modifiers, when applicable. Dr. Smith owns the mammography equipment and contracts with Dr. Jones to read the mammograms for her practice. Code for Dr. Smith’s services. Mammogram Report Date of Service: 8-24-18 MRN: 89-12-34 Primary Provider: Smith Sex: F Ordering Provider: Smith DOB: 09-21-45 History: Screening required per protocol Examinations to be Performed: Bilateral screening mammograms Left breast diagnostic mammogram Bilateral Mammogram: Bilateral two-view film screen mammograms were performed and compared with previous bilateral mammograms from October 11, 2015, and August 11, 2017. There are scattered fibroglandular elements that could obscure a lesion on mammography. Both breasts show no evidence of suspicious calcification. The right breast shows no suspicious masses and no significant interval change in comparison with the prior mammograms. Diagnostic Mammogram: Left breast shows a slightly lobulated 7 × 5 mm nodule in the outer-lower-to-central breast that was not definitely identified on the previous examinations. Two additional localizing views of the left breast are performed. No architectural distortion or secondary findings of malignancy are seen. Impression: 1. Stable right breast mammogram without evidence of malignancy. 2. Left breast showing a new 7 × 5 mm slightly lobulated nodule in the outer-lower-to-central breast. For further evaluation of this finding, a left breast ultrasound is recommended and the Radiology Department will schedule this examination. D: 8-24-18 Mary Jones, M.D. T: 8-25-18

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