Medical Clarified Coding for Bilateral Mammogram

Name: Bilateral Mammogram

Medical Specialty: Obstetrics/Gynecology 

Description: Bilateral Mammogram (abnormal), additional views requested
(Medical Transcription Sample Report)

EXAM: Mammographic screening FFDM

HISTORY: 40-year-old female who is on oral contraceptive pills. She has no present symptomatic complaints. No prior history of breast surgery nor family history of breast CA.

TECHNIQUE: Standard CC and MLO views of the breasts.

COMPARISON: This is the patient's baseline study.

FINDINGS: The breasts are composed of moderately to significantly dense fibroglandular tissue. The overlying skin is unremarkable.

There is a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.

There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.

There are no spiculated masses or architectural distortions.

IMPRESSION: Tiny cluster of calcifications at the 11:30 position of the right breast.

Recommend additional views; spot magnification in the MLO and CC views of the right breast.

BIRADS Classification 0 – Incomplete

MAMMOGRAPHY INFORMATION: 

1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.

 
2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.

 
3. These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.

Scenario Summary (Coding Context)

• Patient: 40-year-old female

• Specialty: OB/GYN/Radiology

• Encounter Type: Screening bilateral mammogram

• Findings: Cluster of calcifications in right breast

• BI-RADS: 0 – Incomplete

• Outcome: Additional diagnostic views recommended, not yet performed

CPT/HCPCS Procedure Codes

Code for this encounter: 

• 77067 – Screening mammography, bilateral (2-view study of each breast), including CAD.

Rationale:

• Exam is explicitly documented as screening mammography (FFDM).

• Patient is asymptomatic.

• No prior breast cancer, surgery, or family history.

• Bilateral CC and MLO views performed.

• CAD software (iCAD Second Look) was used; included in code.

• BI-RADS 0 does not change the screening CPT code for this visit.

Codes not assigned for this encounter:

• 77065/77066 (Diagnostic mammography): Not coded yet—additional views were recommended but not performed.

• Add-on spot magnification codes: Not separately reportable; bundled into diagnostic mammography when performed.

ICD-10-CM Diagnosis Codes

Primary Diagnosis (Screening Visit):

• Z12.31 – Encounter for screening mammogram for malignant neoplasm of breast.

Rationale:

• Patient presents without symptoms.

• Exam purpose was screening.

• Findings discovered during screening do not replace the screening diagnosis for this visit.

Diagnosis codes not used yet:

• R92.1 (Mammographic microcalcification): Not reported until diagnostic imaging is performed.

• N63 (Breast lump): No palpable mass.

• Z80.3 (Family history of breast cancer): Explicitly denied in documentation.

BI-RADS 0 Coding Guidance (Important)

BI-RADS 0 = Incomplete:

• Indicates need for additional imaging.

• Does not convert the screening mammogram into a diagnostic exam.

• Screening CPT remains valid for this encounter.

Coding for the Follow-Up Visit (When Additional Views Are Performed)

These codes are not billed today but are included for coder clarity.

CPT:

• 77065 – Diagnostic mammography, unilateral (right breast), including CAD.

Rationale:

• Additional spot magnification CC and MLO views.

• Imaging limited to right breast.

• CAD included.

ICD-10-CM:

• R92.1 – Mammographic microcalcification.

Rationale:

• Used once imaging is diagnostic.

• Reflects the calcifications identified on screening.

Final Coding Summary

Category Code Description

Key Coding Takeaways

• Screening stays screening, even with abnormal findings.

• BI-RADS 0 does not mean diagnostic exam.

• Do not assign abnormal findings diagnosis codes until diagnostic imaging occurs.

• CAD is included, not separately billable.

For more information, visit:

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Source: Janine Mothershed is the founder and CEO of Coding Clarified, an innovative online medical coding school committed to transforming lives through flexible, high-quality career training. A Certified Professional Coder (CPC) and licensed AAPC instructor, Janine brings over a decade of experience in healthcare administration, medical coding, and workforce development.

Her mission is rooted in making medical coding education accessible, affordable, and employment-focused, offering structured programs that guide students from certification to real-world work experience through remote internships and employer partnerships. Under her leadership, Coding Clarified has become a trusted name among aspiring coders and workforce agencies across the country.

Driven by her own journey of resilience, Janine empowers others to rewrite their stories by providing not just training but support systems that promote confidence, career clarity, and upward mobility. She is also a proud mother of three, a passionate advocate for inclusive learning, and a voice for women entrepreneurs building from the ground up.

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