AMA Clinical Examples in Radiology - 2021 Issue 3 (Summer)
Computed Tomography of the Breast
CLINICAL EXAMPLE 1 Computed Tomography of the Breast CLINICAL HISTORY The patient is an 81-year-old postmenopausal female with a right breast biopsy—proven intermediate grade ductal carcinoma in situ (DCIS) with calcifications and focal comedo necrosis involving the right upper-outer quadrant. Indication for examination is the evaluation for extent of disease and history of newly diagnosed right breast DCIS. The patient is unable to undergo magnetic resonance imaging (MRI) due to an MRI-incompatible aneurysm clip. TECHNIQUE With the patient lying in a prone position, the right and left breasts were scanned using computed tomography (CT) imaging before and after a...
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Article Overview
This article covers a breast CT clinical example, related imaging context, and a discussion of how dedicated breast CT is represented in CPT and ICD-10-CM. It is useful for coders, radiology teams, and compliance staff who need to understand the scope of breast CT reporting and the diagnosis coding referenced in the example. The article also outlines how the topic fits into a newer CPT code set for breast CT and contrasts that category with broader chest CT coding references.
Why This Topic Matters
Breast CT is a specialized imaging service with its own code set, and accurate identification of the study type and linked diagnosis code matters for radiology documentation, claims processing, and coding education.
Article Sections
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Clinical Example 1
A breast CT case example is presented with the clinical context, imaging approach, findings, and assessment summary.
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How to Code
This section identifies the coding referenced for the example and connects the imaging scenario to the applicable classification systems.
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Discussion
The discussion reviews dedicated breast CT coding, the broader context of the newer CPT breast CT code set, and related classification references.
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Table 1. CPT Codes for Unilateral and Bilateral Breast CT
A summary table organizes the breast CT code set by laterality and contrast approach.
What You Will Learn
- The clinical context for a dedicated breast CT example
- The coding systems discussed for breast CT reporting
- How the article frames the breast CT code set within radiology coding
- The diagnosis classification referenced for the example case
- How the article organizes unilateral and bilateral breast CT reporting categories
Who Should Read This
- Radiology coders
- Medical coding professionals
- Breast imaging teams
- Compliance specialists
- Revenue cycle staff
Codes Discussed
Code Ranges Discussed
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