1/12/2007 Fernald Medical Monitoring Program Sort Code Mammogram Coding
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1 1/12/2007 Fernald Medical Monitoring Program Sort Code Mammogram Coding Exam (Test) Performed 1 2 Code Description 3 1 Screening mammogram 4 2 Diagnostic mammogram/recall unilateral mammogram/coned magnification 5 3 Mediolateral oblique 6 4 Craniocaudal 7 5 Mediolateral 8 6 Comparisons with old films (second reading for comparison) 9 7 Other 10 8 Xeromammogram 11 9 Needle aspiration/localization Ultrasound study Frozen section consultation Technically unsatisfactory study Second TU Study on same day Digital Screening Digital Diagnostic Please note that the range for mammogram codes is from 700 to 899. Please do not assign numbers outside of that range to mammogram codes. 20 We will no longer designate mammogram codes as "findings" or "recommendations". For each phrase in the mammogram report, find an appropriate code and write it in the margin near the phrase Use these codes to describe type of view of current film Coned magnification of mediolateral oblique projection (Moderate) skin thickening Coned magnification Coned magnification in craniocaudal projection Cleopatra views Additional views Normal breast, negative No change noted since previous mammogram No changes since last mammogram Skin and nipples unremarkable No signs of breast carcinoma/no suspicious abnormality Stability means most likely benign Stable imaging appearance No dominant mass or suspicious calcification seen/spiculation No distortion seen Unsatisfactory study Motion present Need correct date on film Patient unable to tolerate imaging of breast No comparison films available Comparison films available Need Comparison with old films Review of previous film requested (Previous) study inadequate Placing of a marker (to define a skin lesion, mass) nipple 51
2 Previous biopsy Previous right mastectomy Previous left mastectomy Previous lumpectomy Radiation therapy changes Post-surgical changes, previous surgery, post surgical scarring Surgical removal of calcification, mass, density Minimal post enhancement Bilateral breast implants Unilateral implantation No leakage from implants Extracapsular ruptures (from implants) Foreign body Port a cath in place/shunt, catheter in place No pectoralis muscle due to trauma Changes possibly due to trauma Changes due to differences in compression Changes could represent mastitis Asymmetric breast tissue/stroma Breasts intermediate in density (mild to moderate)(average) Breasts high in density/markedly dense Breasts not symmetric in density Previous density no longer present (Linear density) or scar Density smaller compared to old films Changes consistent with hormone replacement therapy Focal density (central) Asymmetrical density Question of neodensity Areas of focal density also present in previous films Increased density (as compared to previous films) Nodular Density/Opacity Density Density likely within pectoralis muscle Breast pain/tenderness Lipoma Pacemaker in place Surgical/biopsy clips/staples Increased trabeculation Edema Nipple Discharge Diagnosis abnormal Border loss Implants have been removed No breast tissue image (seen) (Bilateral) breast reduction Laterally rotated view 107
3 Fat necrosis Skin changes Skin calcification Palpable abnormality/breast lump Dilated vessels Nipple retraction Nipple retraction Flattening of nipple Prominent ducts seen Hilus Architectural distortion Questionable architectural distortion Digital distortion Areas of distortion Artifact Overlapping/superimpose shadows/summation artifact/overlapping glandular tissue Prominence of the breast parenchyma Fatty parenchymal pattern Overlapping parenchyma Incompletely compressed normal breast parenchyma Parenchymal Pattern is stable Nodules present Nodule present Ill-defined nodule Areas of nodularity Small nodule noted Nodule increased in size since previous films Palpable nodules not seen on mammogram Nodule decreased in size Additional views fail to confirm nodule Tortuous vein Previous nodule no longer present Calcifications Microcalcification Vascular calcification Diffuse vascular calcification Small calcification Punctuate calcification Non-specified punctuate calcification Glandular calcification Large calcification Macrocalcifications Benign calcification (stable) Possible indolent carcinoma Digital Mammogram (Full Field) digital mammography Possible metastasis Neoplasm 163
4 7009 Ductal ectasia Dystrophic calcification Skin lesion, scar Nodule corresponds to skin lesion/nipple Mastitis Previous traumatic breast injury Convexity Calcification of implant Port in place- see possible DCIS f/up in 2 months involutional changes pleomorphic calcificaiton Secretory calcification Milk of calcium Dilated ducts Fibrosis Inverted Nipple Decreased breast size Spiculation (speculated appearance) Linear calcification Increase in calcification Calcification would be difficult to remove via lumpectomy Calcification decreased in number Irregular calcifications Possible calcification Asymmetric opacification (Rounded) opacification, opacity (Scattered areas of) fibrous tissue Mixed fibro/fatty tissue Fibroglandular tissue/thickening (Minimal) glandular tissue present Diffuse increased glandular tissue Mammary dysplasia (fibroglandular thickening) (Scattered) thickening Stromal thickening, density Mass-like density Hypoechoic/mass/structure/cyst Anechoic mass/structure/cyst Solitary hypoechoic mass with thin walls Anechoic mass with thin walls (Moderate) fatty replacement Breast tissue is fatty Echogenicity similar to that of fat Lymph node (noted) Hyperplastic lymph node Other lymph node present Benign lymphatic density Lesion Circumscribed lesion 219
5 766 Specimen indicates inclusion of suspicious lesion Cyst(s) Fibrocystic changes/mastopathy Small cyst Multiple cysts (Likely) benign tumor/nodule/finding (Likely)(suspicious for) malignant tumor/nodule/finding Malignancy Findings consistent with carcinoma Uncertain diagnosis Possible cyst or mass Ovoid dense shadow/density Gynecomastia Intracystic papillary Tumor Axillary adenopathy Mass (present) Mass present Do Not Use (Previous) Mass no longer present Lobulated mass Solid masses by ultrasound Fibroadenoma Calcified fibroadenoma Non-calcified fibroadenoma Calcified hyalinizing fibroadenoma Successful cyst aspiration Moderate brown fluid obtained Post-aspiration coned magnification show pervious (Lack of) Slip of the pectoralis muscle (Post-traumatic) Hematoma/seroma Hamartoma Careful exam of breast If previously evaluated, no further work-up needed Clinical correlation required (Sclerosing) adenosis mass increase in size Routine screenings Repeat screenings with in 30 days/3-4 weeks Repeat mammogram in 6 months Repeat mammogram in one year(not for routine use) Follow-up mammogram in 2 years Repeat mammogram in 3-4 months Additional views needed Repeat coned magnification view in craniocaudal projection Recommend magnified/magnification view 275
6 775 Cleopatra views needed Rolled craniocaudal view recommended Laterally rotated view recommended Recommended post-aspiration mammography Coned magnification recommended Recommended diagnostic mammogram Recommended mediolateral oblique with nipple profile Biopsy recommended Ultrasound study of breast Cyst aspiration recommended Discontinue Hormone Therapy & Repeat Films Galactogram Mammotome Bx(Lg. Core Bx) Stereotactic Biopsy MRI Scanning spectography natography follow up in 5 years Needle localization CT scan recommended Recommendation to see surgeon (Close) clinical follow-up 299 ***************************************************************** 300 RECOMMENDATION CODES...USE THESE CODES FOR RECOMMENDED VIEWS WANTED FOR DIAGNOSTIC SCREENS 301 ***************************************************************** Physician's Initials ASR Alice S Rim 306 CFP Ceclia Feiroglio-Preiser 307 CXP Charles Perme 308 CXR Catherine Richards (Perez)-Catherine Perez 309 DGS Dianne Georgean-Smith 310 HHH H. Hugh Hawkins 311 HLC Helen L. Corcoran 312 HOF Haydee Ojeda-Fournier 313 HXE Hillary Evans 314 JAS Jackie Sweeney 315 JXF Jeanette Fulton 316 KAC K. Ann Choe 317 KXS Kathryn Shumrick 318 LXM Linda Michelson 319 LXR Laura Rice 320 LXS Lawrence Sobel 321 MCM Mary C. Mahoney 322 MWM Martin W. Mitchell 323 MXI Mark Imumuce (?sp) 324 MXM Myron Moskowitz 325 MXO Marsha Orcut, MD 326 RXC Rebecca Corelius 327 SXB Sally Bass 328 SXV Sadhna Verma 329 VXM Virginia Molleran 330
7 WCD William C. Duffey 331 WKL William K. Littman 332
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