AMA Clinical Examples in Radiology - 2025 Issue 3 (Summer)
Contrast-enhanced spectral mammography (CESM)-guided stereotactic breast biopsy
Summer 2025 pages 20-21 RADIOLOGY TEST CASE This radiology test case is provided for coding professionals to test their knowledge. Please take time to review and code the case. Consider your answers as to how the procedure should be reported. Once you are confident of your answer, check the "Radiology Test Case Answer" on page 28 for the correct answer and discussion. Contrast-Enhanced Spectral Mammography (CESM)-Guided Stereotactic Breast Biopsy CLINICAL INDICATION A 54-year-old female presents with a history of left breast cancer, status post-mastectomy 3 years prior. She has a cardiac pacing device that is not magnetic resonance imaging...
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Article Overview
This article presents a breast imaging test case from Summer 2025 that reviews a contrast-enhanced mammography scenario involving CESM-guided stereotactic biopsy. It is intended for coding professionals who want to assess how the procedure is approached when the targeted finding is not visualized during the study. The case is relevant to radiology and breast imaging coders, and it centers on imaging workflow, procedural setup, and follow-up planning rather than treatment.
Why This Topic Matters
Breast imaging procedures can involve specialized contrast-enhanced mammography workflows and guidance methods that affect code selection. This case helps coders evaluate whether a reported biopsy attempt, imaging guidance approach, and procedure discontinuation are captured appropriately in a radiology record.
Article Sections
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Summer 2025 pages 20-21
Introductory test-case material for a radiology coding exercise. Provides the setting and purpose of the case within a training format.
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Clinical Indication
Patient history and imaging context for a breast lesion evaluation. Summarizes the clinical scenario that led to the procedure.
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Procedure
Overview of the planned breast biopsy procedure using contrast-enhanced mammography guidance. Describes the procedural intent and target area.
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Technique
Step-by-step procedural setup, contrast administration, positioning, and imaging workflow. Includes the circumstances under which the procedure was stopped.
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Impression
Summary of the imaging outcome and follow-up recommendation. Presents the final assessment from the test case.
What You Will Learn
- How a contrast-enhanced mammography-guided breast biopsy case is presented in a radiology coding test format.
- What parts of the clinical scenario and procedure workflow are highlighted for coding review.
- How imaging nonvisualization and follow-up recommendations are documented in the case format.
- How a breast imaging procedure may be described when a planned biopsy is not completed.
Who Should Read This
- Radiology coders
- Breast imaging coding professionals
- Coding auditors
- Health information management professionals
- Medical coding educators
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