Name of the Procedure:

Screening, diagnostic, film, digital, or digital breast tomosynthesis (3D) mammography results were not documented and reviewed, reason not otherwise specified (HCPCS Code G9900)

Summary

A mammography is a specialized medical imaging test used to screen for and diagnose breast cancer. This procedure can be performed using traditional film, digital methods, or advanced 3D breast tomosynthesis. The specific code G9900 refers to instances where the results of the mammogram were not documented and reviewed, without a specified reason.

Purpose

The primary purpose of a mammography procedure is to detect signs of breast cancer early when it is most treatable. This diagnostic tool is crucial for finding tumors that are too small to be felt during a physical examination.

Indications

• Routine breast cancer screening, typically recommended for women starting at age 40.
• Evaluation of breast lumps or other abnormal findings.
• Follow-up on abnormal screening results.
• Monitoring known breast conditions.

Preparation

• Avoid using deodorants, perfumes, or powders on the day of the exam as they can interfere with imaging.
• Wear a two-piece outfit to make it easier to undress from the waist up.
• Inform the technician if there is any chance of pregnancy.

Procedure Description

1. The patient undresses from the waist up and wears a provided gown.
2. The patient stands in front of the mammography machine.
3. The technologist positions the breast on a flat support plate.
4. Another plate compresses the breast to spread out the tissue for clearer images.
5. Images are taken from different angles for a comprehensive view.
6. For digital breast tomosynthesis (3D mammography), the X-ray tube moves in an arc around the breast.
7. The entire procedure typically involves minimal discomfort.

Duration

The procedure generally takes about 20 minutes, including the time for positioning and taking the images. The actual compression time is less than a minute per image.

Setting

Mammography is performed in a specialized radiology department within a hospital, outpatient clinic, or diagnostic imaging center.

Personnel

• Radiologic Technologist (performs the mammogram)
• Radiologist (reads and interprets the images)
• Sometimes nurses and support staff for additional patient guidance.

Risks and Complications

• Exposure to a low dose of radiation.
• Potential discomfort or pain from breast compression.
• Rarely, false-positive or false-negative results can occur, leading to unnecessary anxiety or missed diagnosis.

Benefits

• Early detection of breast cancer increases the chances for successful treatment.
• Can identify abnormalities before symptoms develop.
• 3D mammography can provide more detailed images, improving detection rates.

Recovery

• No recovery time is needed; patients can resume normal activities immediately.
• Results are typically reviewed within a few days, though this category refers to cases where documentation and review did not occur as intended.

Alternatives

• Ultrasound: Useful for evaluating specific areas of concern found in mammography.
• MRI: Provides detailed images of the breast, especially for high-risk patients.
• Clinical Breast Exam (CBE): Physical examination performed by a healthcare provider.

Patient Experience

• Some may experience brief discomfort from breast compression.
• Patients should notify the technologist if the compression is too painful.
• The sensation is momentary, and effective communication with the technologist can help reduce anxiety.