A 35-year-old female has cancer in her left breast. The surgeon performs a mastectomy, removing the breast tissue, skin, pectoral muscles, and surrounding tissue, including the axillary and internal mammary lymph nodes.
Which mastectomy code is reported?
The procedure performed is a bilateral screening mammogram with computer-aided detection (CAD). CPT code 77067 is for bilateral screening mammography with CAD. ICD-10-CM code Z12.31 is for an encounter for screening mammogram for malignant neoplasm of the breast. Z80.3 is for a family history of malignant neoplasm of the breast. Therefore, the correct coding is 77067, Z12.31, Z80.3. Reference: CPT Professional Edition (current year), ICD-10-CM (current year).
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