ICD-10 Coding for Abnormal Mammogram Findings(R92.0, R92.2, R92.8)
Complete ICD-10-CM coding and documentation guide for Abnormal Mammogram Findings. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Mammogram Findings
R92Primary Range
Abnormal findings on diagnostic imaging of breast
This range includes codes for specific types of abnormal findings detected during mammographic imaging.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R92.0 | Mammographic microcalcification found on diagnostic imaging of breast | Use when mammogram reveals microcalcifications, typically BI-RADS 4 or 5. |
|
| R92.2 | Inconclusive mammogram | Use when mammogram results are inconclusive due to factors like dense breast tissue. |
|
| R92.8 | Other abnormal and inconclusive findings on diagnostic imaging of breast | Use for abnormal findings not specified under other R92 codes. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for abnormal mammogram findings
Essential facts and insights about Abnormal Mammogram Findings
Primary ICD-10-CM Codes for abnormal mammogram findings
Decision Criteria
clinical Criteria
- Presence of microcalcifications on mammogram
Applicable To
- Clustered microcalcifications
Excludes
- Calcifications not specified as microcalcifications
Clinical Validation Requirements
- BI-RADS assessment indicating microcalcifications
- Radiology report specifying location and type of calcifications
Code-Specific Risks
- Misclassification if calcifications are not specified as microcalcifications
Coding Notes
- Ensure documentation specifies 'microcalcifications' to use R92.0.
R92.2 - Inconclusive mammogram
Use when mammogram results are inconclusive due to factors like dense breast tissue.
Applicable To
- Dense breast tissue obscuring visualization
Excludes
- Normal mammogram findings
Clinical Validation Requirements
- Radiology report indicating inconclusive results due to technical factors
Coding Notes
Ensure documentation supports the inconclusive nature of the mammogram.
R92.8 - Other abnormal and inconclusive findings on diagnostic imaging of breast
Use for abnormal findings not specified under other R92 codes.
Applicable To
- Asymmetric density
- Architectural distortion
Excludes
- Findings specified under other R92 codes
Clinical Validation Requirements
- Radiology report detailing specific abnormal findings
Coding Notes
Document specific findings to justify use of R92.8.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for screening mammogram for malignant neoplasm of breast
Z12.31Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Mammogram Findings to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R92.0.
Impact
Clinical: Inadequate follow-up recommendations, Regulatory: Non-compliance with reporting standards, Financial: Potential claim denials
Mitigation Strategy
Standardize BI-RADS inclusion in reports, Educate staff on importance of BI-RADS
Impact
Reimbursement: May lead to claim denials, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data representation
Mitigation Strategy
Ensure mammogram is documented as inconclusive before using R92.2.
Impact
Lack of BI-RADS documentation can trigger audits.
Mitigation Strategy
Ensure all mammogram reports include BI-RADS category.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Abnormal Mammogram Findings, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Mammogram Findings
Use these documentation templates to ensure complete and accurate documentation for Abnormal Mammogram Findings. These templates include all required elements for proper coding and billing.
Screening mammogram with abnormal findings
Specialty: RadiologyRequired Elements
- Indication for mammogram
- BI-RADS category
- Description of findings
- Comparison to prior studies
- Recommendations
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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