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ICD-10 Coding for Dense Breasts(R92.30, R92.31, R92.32, R92.33, R92.34)

Complete ICD-10-CM coding and documentation guide for Dense Breasts. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Breast DensityMammographic Density

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Related ICD-10 Code Ranges

Complete code families applicable to Dense Breasts

R92.30-R92.34Primary Range

Abnormal findings on diagnostic imaging of breast

This range includes codes specific to breast density findings on mammography, categorized by BI-RADS.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
R92.30Unspecified abnormal mammogramUse when mammogram indicates dense breasts without specifying BI-RADS category or laterality.
  • Mammogram report stating 'dense breasts' without BI-RADS classification
R92.31Fatty replaced breasts (BI-RADS A)Use when mammogram indicates fatty replaced breasts with BI-RADS A classification.
  • BI-RADS A classification in mammogram report
R92.32Scattered fibroglandular density (BI-RADS B)Use when mammogram indicates scattered fibroglandular density with BI-RADS B classification.
  • BI-RADS B classification in mammogram report
R92.33Heterogeneously dense (BI-RADS C)Use when mammogram indicates heterogeneously dense breasts with BI-RADS C classification and specified laterality.
  • BI-RADS C classification in mammogram report
  • Laterality specified
R92.34Extremely dense (BI-RADS D)Use when mammogram indicates extremely dense breasts with BI-RADS D classification and specified laterality.
  • BI-RADS D classification in mammogram report
  • Laterality specified

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 dense breasts

Essential facts and insights about Dense Breasts

The ICD-10 code for dense breasts is R92.30 for unspecified density, with specific codes R92.31-R92.34 based on BI-RADS classification.

Primary ICD-10-CM Codes for breast dense

R92.30
Unspecified abnormal mammogram
Billable Code

Decision Criteria

documentation Criteria

  • Mammogram report lacks BI-RADS classification

Applicable To

  • Dense breasts without further specification

Excludes

  • Inconclusive mammogram (R92.2)

Clinical Validation Requirements

  • Mammogram report stating 'dense breasts' without BI-RADS classification

Code-Specific Risks

  • May lead to audits if used without BI-RADS classification

Coding Notes

  • Ensure documentation specifies the need for further imaging if applicable.
View Full Code Details

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Inconclusive mammogram

R92.2
Use R92.2 only if the mammogram is inconclusive, not solely due to density.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Dense Breasts to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R92.30.

Impact

Clinical: May lead to inappropriate follow-up recommendations., Regulatory: Non-compliance with coding guidelines., Financial: Potential claim denials due to incomplete documentation.

Mitigation Strategy

Implement mandatory BI-RADS classification fields in reporting software., Conduct regular training sessions for radiology staff.

Impact

Reimbursement: Incorrect coding can lead to claim denials., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate data reporting and potential audit triggers.

Mitigation Strategy

Use R92.3x codes for density findings and R92.2 only if the mammogram is inconclusive.

Impact

Reimbursement: Claims may be denied for incomplete coding., Compliance: Non-compliance with specificity requirements., Data Quality: Incomplete data affecting clinical decision-making.

Mitigation Strategy

Query provider for side specificity and use the appropriate 6th digit.

Impact

Failure to include BI-RADS classification and laterality in reports.

Mitigation Strategy

Implement documentation audits and provide feedback to radiologists.

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 Dense Breasts, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Dense Breasts

Use these documentation templates to ensure complete and accurate documentation for Dense Breasts. These templates include all required elements for proper coding and billing.

Radiology Report for Dense Breasts

Specialty: Radiology

Required Elements

  • BI-RADS classification
  • Laterality
  • Impact statement on mammographic sensitivity

Example Documentation

BREAST DENSITY ASSESSMENT: Composition: BI-RADS C, Laterality: Bilateral, Impact: Dense tissue may lower mammographic sensitivity. Consider supplemental screening with ABUS per ACR guidelines.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Mammogram shows dense breasts.
Good Documentation Example
Screening mammogram demonstrates heterogeneously dense breast parenchyma (BI-RADS C) bilaterally, requiring supplemental ultrasound per ACR guidelines.
Explanation
The good example provides specific BI-RADS classification and laterality, which are necessary for accurate coding and clinical decision-making.

Need help with ICD-10 coding for Dense Breasts? Ask your questions below.

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