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AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2022 Issue 3; Ask the Editor

Lump/Mass Status Post Bilateral Mastectomy with Reconstruction

A 38-year-old female presents to the Radiology Department for a right breast ultrasound. The reason for the test is documented as “lump or mass in breast.” The final ultrasound impression demonstrates, “Stable elongated hypoechoic foci adjacent to the implant in the area of the palpable lump/thickening noted clinically, these findings are benign-appearing and stable.” Is it appropriate to assign a code for a condition of the breast, when a patient is status post bilateral mastectomies? What are the correct codes assigned for this outpatient encounter? ...

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