A 45-year-old female patient presents for a screening mammogram. Upon examination, the screening test shows evidence of a calcification in the left breast. How would the coder appropriately assign diagnosis codes for this service?

Question

Quizplus · Accepted Answer

The correct approach is to first list the code for the screening mammogram because the primary reason for the encounter is the screening. If a finding such as a breast mass or calcification is discovered during the screening, the code for that finding (in this case, the breast mass or calcification) should be listed secondarily. This ensures that the primary reason for the visit (the screening) is accurately captured, followed by any incidental findings.

A 45-Year-Old Female Patient Presents for a Screening Mammogram