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jpierce31

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Can i bill a e/m code with this plus the mammo codes?

Radiology Report Text:
CLINICAL HISTORY: LEFT lumpectomy and accelerated partial breast radiation 10 o'clock for a 0.9 cm mass with pathology of grade 2 infiltrating ductal carcinoma and minimal DCIS with negative sentinel node dissection January 2013. At time of lumpectomy there was a retroareolar excisional biopsy yielding atypical ductal and lobular hyperplasia, which was prompted by a positive preoperative PEM scan. Subsequent postoperative stereotactic biopsy for outer quadrant ipsilateral breast 11/19/2013 for microcalcifications yielded benign concordant pathology.

PREVIOUS STUDIES: BILATERAL mammogram 10/9/2017, LEFT mammogram 4/12/2017, 10/6/2016, 3/10/2016, 10/05/2015 dating back to 08/09/2010.

LEFT DIAGNOSTIC MAMMOGRAM FINDINGS: Routine 2-D and 3-D digital images were obtained. The study was interpreted with the assistance of a computer aided detection program. There are scattered fibroglandular densities. There are stable postsurgical and radiation changes at 10 o'clock with distortion and dystrophic calcifications concordant with fat necrosis. There is a circumscribed 3.5 cm mass at 2 o'clock, a known cyst as per prior sonograms. There is a tissue marker upper outer quadrant denoting benign biopsy site. No suspicious abnormality is identified.

CLINICAL BREAST EXAM: Palpable mass LEFT breast 2 o'clock 12 cm from the nipple corresponding to known cyst.

The findings and recommendations were discussed with the patient on 5/8/2018.

IMPRESSION:
1. Postsurgical/radiation changes LEFT breast without evidence of a new or recurrent cancer.

RECOMMENDATION: As per postlumpectomy protocol, continued six month interval surveillance of the postlumpectomy breast and yearly exam of the contralateral breast.

ACR BI-RADS Category 2 - Benign

 


IN SUMMARY
Tissue Density^There are scattered areas of fibroglandular density.
Recall Type^Screening mammogram
Recall Interval^6 months
BI-RADS^BI-RADS 2: Benign
A Letter^Post Lumpectomy 6 month

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