ICD-10 Coding for Dense Breast Tissue(R92.30, R92.31)
Complete ICD-10-CM coding and documentation guide for Dense Breast Tissue. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dense Breast Tissue
R92.3Primary Range
Abnormal and inconclusive findings on diagnostic imaging of breast
This range includes codes specific to dense breast tissue findings on 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 |
|---|---|---|---|
| R92.30 | Unspecified abnormal mammogram | Use when dense breast tissue is noted but not further specified. |
|
| R92.31 | Mammographic microcalcification found on diagnostic imaging of breast | Use when heterogeneously dense tissue is documented. |
|
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 breast tissue
Essential facts and insights about Dense Breast Tissue
Primary ICD-10-CM Codes for dense breast tissue
Decision Criteria
documentation Criteria
- Presence of dense breast tissue without specific BI-RADS category
Applicable To
- Dense breast tissue, unspecified
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- Mammogram report indicating dense breast tissue without specific BI-RADS category
Code-Specific Risks
- May lead to under-documentation if specific density is not recorded.
Coding Notes
- Ensure documentation specifies the BI-RADS category if available.
R92.31 - Mammographic microcalcification found on diagnostic imaging of breast
Use when heterogeneously dense tissue is documented.
Applicable To
- Heterogeneously dense breast tissue
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- Mammogram report indicating heterogeneously dense tissue (BI-RADS C)
Coding Notes
Ensure BI-RADS category is documented.
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
Z12.31Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dense Breast Tissue 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 or delays.
Mitigation Strategy
Ensure radiologists include BI-RADS in reports., Train staff on documentation standards.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate data on breast density prevalence.
Mitigation Strategy
Use R92.3x codes unless the mammogram is inconclusive.
Impact
Using R92.2 for dense breast tissue without inconclusive findings.
Mitigation Strategy
Educate coders on correct code usage post-2023 update.
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 Breast Tissue, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dense Breast Tissue
Use these documentation templates to ensure complete and accurate documentation for Dense Breast Tissue. These templates include all required elements for proper coding and billing.
Routine Screening Mammogram
Specialty: RadiologyRequired Elements
- BI-RADS category
- Description of breast density
- Recommendation for follow-up
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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