ICD-10 Coding for Breast Density(R92.30, R92.31, R92.32, R92.33, R92.34)
Complete ICD-10-CM coding and documentation guide for Breast Density. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Breast Density
R92.30-R92.34Primary Range
Codes for breast density findings
These codes are used to specify findings related to breast density as assessed by mammography.
Code for inconclusive mammogram
This code is used when a mammogram is inconclusive, not specifically for density findings.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R92.30 | Dense breasts, unspecified | Use when the report states 'dense breasts' without specifying type or laterality. |
|
| R92.31 | Almost entirely fatty breast density | Use when the report specifies 'almost entirely fatty' breast tissue. |
|
| R92.32 | Scattered fibroglandular breast density | Use when the report specifies 'scattered fibroglandular densities'. |
|
| R92.33 | Heterogeneously dense breast density | Use when the report specifies 'heterogeneously dense' breast tissue. |
|
| R92.34 | Extremely dense breast density | Use when the report specifies 'extremely dense' breast tissue. |
|
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 breast density
Essential facts and insights about Breast Density
Primary ICD-10-CM Codes for breast density
Decision Criteria
documentation Criteria
- Presence of 'dense breasts' without BI-RADS classification
Applicable To
- Dense breast tissue without specific BI-RADS classification
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- Documentation stating 'dense breasts' without further specification
Code-Specific Risks
- Risk of undercoding if specific density type is documented but not coded.
Coding Notes
- Ensure documentation does not specify a BI-RADS category before using this code.
R92.31 - Almost entirely fatty breast density
Use when the report specifies 'almost entirely fatty' breast tissue.
Applicable To
- BI-RADS Category A
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- BI-RADS Category A or equivalent terminology
Coding Notes
Ensure laterality is documented.
R92.32 - Scattered fibroglandular breast density
Use when the report specifies 'scattered fibroglandular densities'.
Applicable To
- BI-RADS Category B
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- BI-RADS Category B or equivalent terminology
Coding Notes
Ensure laterality is documented.
R92.33 - Heterogeneously dense breast density
Use when the report specifies 'heterogeneously dense' breast tissue.
Applicable To
- BI-RADS Category C
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- BI-RADS Category C or equivalent terminology
Coding Notes
Ensure laterality is documented.
R92.34 - Extremely dense breast density
Use when the report specifies 'extremely dense' breast tissue.
Applicable To
- BI-RADS Category D
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- BI-RADS Category D or equivalent terminology
Coding Notes
Ensure laterality is documented.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Breast Density to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R92.30.
Impact
Clinical: Leads to inaccurate clinical data., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Use specific BI-RADS terminology, Ensure laterality is documented
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with updated coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use R92.3x codes for density findings; R92.2 is for inconclusive results.
Impact
Reimbursement: Claims may be denied for lack of specificity., Compliance: Failure to meet coding specificity requirements., Data Quality: Incomplete clinical data.
Mitigation Strategy
Ensure laterality is documented; query provider if missing.
Impact
Inaccurate or incomplete documentation of BI-RADS classification and laterality.
Mitigation Strategy
Ensure all mammogram reports include specific BI-RADS classification and laterality.
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 Breast Density, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Breast Density
Use these documentation templates to ensure complete and accurate documentation for Breast Density. These templates include all required elements for proper coding and billing.
Breast Density Assessment
Specialty: RadiologyRequired Elements
- BI-RADS classification
- Laterality
- Impact on mammography sensitivity
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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