Question:

One of our breast-center doctors does not specify tomosynthesis in the technique section of mammograms, but tomosynthesis views are mentioned in the body of the report. Does she have to dictate them in the technique or will it be enough that it is mentioned in the body?

Answer:

While it is a best practice that there is a technique section and that it is complete, as long as you can determine that “regular” 2D digital mammography, as well as “3D” tomosynthesis views, were performed, then you can code both. See the Fall 2020 Clinical Examples in Radiology newsletter for a Q & a from the American Medical Association (AMA) and the American College of Radiology (ACR ) regarding this.

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