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

When a patient presents for a screening and a condition is discovered during the screening, the appropriate coding practice is to list the code for the screening first, followed by the code for the condition found. This indicates that the primary reason for the visit was for screening, and the condition (in this case, breast mass or calcification) was a secondary finding.

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