BREAST EXAM:

AuduBon-Bons

Bite Sized

Learning for Clinic

BREAST EXAM:

DOCUMENTATION OF BENIGN EXAM

Week 26

Prepared by Stephanie Warsheski, MD

Homework Assignment:

ACOG Practice Bulletin #179

Breast Cancer Risk Assessment and Screening in

Average-Risk Women

LEARNING OBJECTIVES

• To understand indications and guidelines for the clinical breast exam

• To review components of a complete clinical breast exam

• To effectively document a benign breast exam

CASE VIGNETTE

• A 38 y.o. G2P2 woman presents to clinic requesting a breast

examination. She states her friend was recently diagnosed with

breast cancer and she wants to make sure she doesn’t have it too.

• She has no complaints.

FOCUSED HISTORY

What elements of this patient’s history are most relevant?

• OBHx: FT NSVD x 2

• GYNHx: Menarche at 11 y.o., regular menses q month, lasting 4-5 days, LMP

1 week ago

• PMHx: Denies

• PSHx: Denies

• Meds: None

• All: NKDA

• SocHx: Denies use of tobacco, illicit drugs, + social ETOH

• FamHx: Denies h/o breast, ovarian cancer

Breast cancer risk assessment and screening in average-risk women. Practice Bulletin No. 179.

American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e1–16.

CLINICAL ANATOMY

https://obgynkey.com/the-breast/

INDICATIONS

TECHNIQUE - INSPECTION

• Seated position facing examiner

• Hands on hips

• Hands raised above head

• Assess

• Size

• Shape

• Symmetry

• Nipples

• Size

• Shape

• Texture

• Color

https://obgynkey.com/breast-disorders-2/

TECHNIQUE - PALPATION

• Use pads of the middle 3 fingers

of one hand

• Press downward using circular

motions

• Apply steady pressure, pushing

down to the level of the chest

wall

• Start with breast followed by

axillary region

https://obgynkey.com/breast-disorders-2/

PHYSICAL EXAM, DOCUMENTATION

• Symmetry

• Symmetrical or asymmetrical

• Shape

• Ptotic, pendulous, presence of scars or deformities with description

• Texture

• Soft, nodular, fibrocystic, dense, presence of inframammary ridge in large breasts

• Masses

• Absent

• Present: size, consistency, distance from areolar edge, clock position

• Nipple-areolar complex

• Pink, brown, everted, inverted, discharge present/absent with description, presence of dry, scaly texture

concerning for Paget’s disease

• Skin

• Warm, dry, presence/absence of erythema, edema, peau d’orange appearance, open sores, draining fluid

collections

https://aestheticsjournal.com/feature/lifting-the-breast-with-pdo-threads

https://coremedicalclinics.co.uk/inverted-

nipple-correction/

Karakas C. Paget's disease of the breast. J Carcinog [serial online] 2011 [cited 2019 Sep 4];10:31.

Available from: http://www.carcinogenesis.com/text.asp?2011/10/1/31/90676

http://earthwidesurgicalfoundation.blogspot.com/20

12/01/what-is-diagnosis_25.html

Screening policies should be implemented and focus on high-risk populations that are less

likely to be screened for breast cancer by trained health care providers.

SOCIAL DETERMINANTS OF HEALTH

Lower

rates were

associated

with:

Race: Hispanic or Latino, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska

Native

Age: Women ≥ 75 years

Education: High school education or less

Income: Household income ≤ $25,000

Region of Residence: Midwest

Socio-demographic factors and region of residence are significantly associated with

disparities in receiving CBE in women ≥ 18 years in the United States.

Epic .phrase

BBonBreastExam

Description: Documentation of the breast exam

The patient was examined in 2 positions. The breasts were noted

to be symmetric/asymmetric***, ptotic/pendulous/presence of

scars or deformities***, soft/nodular/fibrocystic/dense/presence of

inframammary ridge***, no masses palpated/mass present (size,

consistency, distance from areolar edge, clock position)***. The

nipple-areolar complexes were pink***, everted/inverted***,

without discharge/discharge present (describe)***, with normal

texture/with presence of dry, scaly texture***. The skin was

warm/dry/with or without erythema/edema/peau d’ orange

appearance/open sores/draining fluid collections***.

CODING AND BILLING

• Diagnostic Codes (ICD-10)

• Z12.39 Encounter for other screening for malignant neoplasm of breast

HISTORY EXAM MEDICAL DIAGNOSIS MAKING CODE APPLICABLE GUIDELINES

Problem focused:

Chief complaint

HPI (1-3)

Problem focused:

- 1 body system

Straight forward:

Diagnosis: minimal

Data: minimal

Risk: minimal

99201

Personally provided

Primary care exception

Physicians at teaching hospitals

Expanded problem focused:

Chief complaint

HPI (1-3)

ROS (1-3)

Expanded problem focused:

- Affected areas and others

Straight forward:

Diagnosis: minimal

Data: minimal

Risk: minimal

99202

Personally provided

Primary care exception

Physicians at teaching hospitals

Comprehensive

Chief complaint

HPI (4)

ROS (2-9)

Past, family, social history (1)

Detailed:

- 7 systems

Low:

Diagnosis: limited

Data: limited

Risk: low

99203

Personally provided

Primary care exception

Physicians at teaching hospitals

Comprehensive

Chief complaint

HPI (4+)

ROS (10+)

Past, family, social history (3)

Comprehensive:

- 8 or more systems

Moderate:

Diagnosis: multiple

Data: moderate

Risk: moderate

99204

Personally provided

Physicians at teaching hospitals

Comprehensive

Chief complaint

HPI (4+)

ROS (10+)

Past, family, social history (3)

Comprehensive:

- 8 or more systems

High:

Diagnosis: extended

Data: extended

Risk: high

99205

Personally provided

Physicians at teaching

hospitals

CODING AND BILLING – NEW PATIENT

HISTORY

EXAM

MEDICAL DIAGNOSIS MAKING

CODE

APPLICABLE GUIDELINES

Expanded problem focused:

Chief complaint

HPI (1-3)

Problem focused:

1 body system

Straight forward:

Diagnosis: minimal

Data: minimal

Risk: minimal

99212

Personally provided

Primary care exception

Physicians at teaching hospitals

Expanded problem focused:

Chief complaint

HPI (1-3)

ROS (1)

Expanded problem

focused:

Affected area and others

Low:

Diagnosis: limited

Data: limited

Risk: low

99213

Personally provided

Primary care exception

Physicians at teaching hospitals

Detailed

Chief complaint

HPI (4+)

ROS (10+)

Past, family, social history (3)

Detailed:

7 systems

Moderate:

Diagnosis: multiple

Data: moderate

Risk: moderate

99214

Personally provided

Physicians at teaching hospitals

Comprehensive

Chief complaint

HPI (4+)

ROS (10+)

Past, family, social history (2)

Comprehensive:

8 or more systems

High:

Diagnosis: extended

Data: extended

Risk: high

99215

Personally provided

Physicians at teaching

hospitals

CODING AND BILLING – ESTABLISHED PATIENT

EVIDENCE

• References

• Breast cancer risk assessment and screening in average-risk women. Practice Bulletin No.

179. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e1–16.

• Breast examination. UCSD’s Practical Guide to Clinical Medicine.

https://meded.ucsd.edu/clinicalmed/breast.htm (Accessed on August 20, 2019).

• Diagnosis and management of benign breast disorders. Practice Bulletin No. 164. American

College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e141–56.

• Henderson JA, Ferguson T. Breast Examination Techniques. [Updated 2019 Jun 7]. In:

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK459179/ (Accessed on August 20, 2019).

• Mikayla Y. Charles, et al. Disparities in receiving clinical breast examination for early

detection of breast cancer among women aged 18 years and over in the United States.

[abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health

Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015;

Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3

Suppl):Abstract nr B95.