Key Points to remember regarding Breast coding

High-risk screening consists of:

Birads classification for coding
BIRADS
- Has a personal hx of breast ca
- Has a mother, sister, or daughter who has breast ca
- Has not given birth prior to age 30
- Has a personal hx of bx-proven benign breast disease*

(*Please note that the last one states breast ‘disease’, and at the time of the initial
guidelines, CMS referred to fibrocystic breast disease for this.)

Kindly make use of Bi-rads classification and PQRS crosswalk. 


while coding screening mammograms, Please note classification 1
and 2 does not require a secondary diagnosis added since there is no follow up suggested on these cases. There would not be cases where the impression state Birads 1 or 2 and still says a follow-up mammogram is recommended. The rest of the classification(0,3,4,5, and 6) need a secondary diagnosis to indicate the follow-up.


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