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Annual gynecological examination; clinical breast examination without pelvic evaluation

HCPCS code

Name of the Procedure:

Annual Gynecological Examination; Clinical Breast Examination without Pelvic Evaluation

Summary

The clinical breast examination (CBE) is part of an annual gynecological check-up in which a healthcare provider examines the breasts for any abnormalities, such as lumps or changes in size or shape, without conducting a pelvic examination. This procedure is important for early detection of breast conditions, including breast cancer.

Purpose

The primary purpose of the CBE is to detect any signs of breast diseases early, particularly breast cancer. The goal is to identify any unusual changes in the breast tissue to facilitate early intervention and treatment if necessary.

Indications

  • Routine annual health check-up.
  • Family history of breast cancer.
  • Patient-reported breast pain, lumps, or discharge.
  • Follow-up for previous breast abnormalities or issues.
  • Monitoring after breast surgery or treatment for breast diseases.

Preparation

  • No specific preparation such as fasting is needed.
  • Check with your healthcare provider if you need to avoid using deodorants or lotions on the day of the examination, as they can interfere with visual inspection.

Procedure Description

  1. The healthcare provider will explain the procedure and answer any questions.
  2. The patient will remove clothing from the waist up and wear a gown that opens in the front.
  3. The provider will visually inspect the breasts for any abnormalities in size, shape, or skin texture.
  4. A hands-on examination will follow, during which the provider palpates the entire breast area, including the armpits, to feel for lumps or thickened tissue.
  5. The patient may be asked to change positions (e.g., lying down, sitting up) to facilitate a thorough examination.

    Typically, anesthesia or sedation is not required for this procedure.

Duration

The examination typically takes about 10 to 15 minutes.

Setting

The procedure is usually performed in an outpatient setting, such as a doctor's office or clinic.

Personnel

  • A gynecologist or a primary care physician.
  • A nurse or medical assistant may be present to assist.

Risks and Complications

  • Minimal risks are associated with a CBE.
  • Possible discomfort during the palpation of breast tissue.
  • Rarely, false-positive or false-negative results may occur, potentially leading to further testing or missed diagnosis.

Benefits

  • Early detection of breast abnormalities can lead to prompt treatment, which can improve outcomes.
  • Provides a routine check-up to monitor changes in breast health.

Recovery

  • There is no recovery period needed; patients can resume normal activities immediately after the examination.
  • Follow any additional instructions given by the provider if an abnormality is detected.

Alternatives

  • Mammography: A more detailed imaging test that can detect smaller abnormalities.
  • Breast Ultrasound: Used for further investigation of abnormalities found during CBE.
  • Self-Examination: Empowering patients to check their own breasts regularly.

Patient Experience

  • Patients might feel a slight discomfort during palpation.
  • Communication with the healthcare provider can help ensure comfort and understanding throughout the procedure.
  • No pain medication is typically necessary but can be discussed if the patient is anxious.

The clinical breast examination is a key component of proactive breast health management, promoting early detection and peace of mind for patients.

Medical Policies and Guidelines for Annual gynecological examination; clinical breast examination without pelvic evaluation

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