Question

What is the professional code and ICD-10-CM codes for this case? The patient is a 34-year-old woman seen in the office last week because of breast discomfort. Her breasts are very uncomfortable because she was immediately premenstrual, so I suggested that she return to the office this week. Her last period began last Sunday. She states that all the breast discomfort has resolved and none is present today. PHYSICAL EXAMINATION: GENERAL: She is a well-developed, well-nourished woman of stated age in no acute distress. Her blood pressure is 100/70, temperature is 99 degrees, pulse is 79 and respirations are 12. BREASTS: Inspection of the right breast reveals no skin or nipple changes. Palpation reveals moderate fibrocystic thickening throughout the entire breast, most pronounced in the upper outer quadrant. No masses are present and there is no axillary adenopathy. Inspection of the left breast reveals no skin or nipple changes. Again, palpation reveals moderate fibrocystic thickening throughout the breasts, it is most pronounced in the upper outer quadrant, but no masses are present and there is no axillary adenopathy. ASSESSMENT AND PLAN: The patient is a 34-year-old woman with significant fibrocystic condition on physical examination and is most likely accounts for the breast discomfort that she was experiencing prior to her. The last visit, I calculated that her lifetime risk of developing breast cancer is probably over 20%, so this warrants increased breast cancer surveillance. I spent 10 minutes of this 15-minute visit today counseling the patient regarding that. I gave her a handout about benign breast anatomy and common benign breast conditions. I reviewed the diagram about normal breast anatomy and then explained to her that fibrocystic condition is most likely causing the symptoms that she is noticing with her breasts. I explained that fibrocystic condition is a benign common condition in women before menopause. I reviewed an anatomic description and written description. I explained that fibrocystic condition causes the density of the breast commonly seen on mammogram in a premenopausal woman. At any rate, I encouraged her to perform monthly breast self-examination, which I do think she will do. I advised a twice yearly clinical breast examination in this office and I recommended a screening mammogram once a year and a screening MRI once a year, but 6 months apart. The patient inquired about an ultrasound, so that will also be scheduled along with a mammogram. I will go ahead and schedule the mammogram and ultrasound and we will see her in 6 months and then she will have the MRI scheduled at the next visit. Her questions are answered and she is comfortable with this plan.

Answer 1

Answer:

This patient is diagnosed with fibrocystic breast. In order to prevent the process of fibrocystic breast they have asked for a regular mammogram every 6 months.

The ICD 10 Code for this case is

ICD-10-CM Code N60.19 - Diffuse cystic mastopathy of unspecified breast.