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Ask a Rev Cycle Expert: MRI Breast Imaging Reporting?

Question:

When magnetic resonance imaging (MRI) is performed on patients with a mastectomy, we perform the MRI on the remaining breast. For the breast that had the mastectomy, we image the chest wall and axillary area, and provide an interpretation. Should a bilateral or unilateral be reported?

Answer:

For your scenario, consider reporting the service as a bilateral procedure. Although the mastectomy has been performed, there may be residual breast tissue left behind. The tissues examined can include the axilla, skin, pectoral muscles and chest wall, etc.

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