ICD-10 Coding for Dense Breast(R92.30, R92.31, R92.32, R92.33, R92.34)
Complete ICD-10-CM coding and documentation guide for Dense Breast. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dense Breast
R92.30-R92.34Primary Range
Abnormal findings on diagnostic imaging of breast
This range includes codes for different types of breast density findings on mammograms.
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 mammographic density | Use when mammogram indicates dense breast tissue but does not specify the type. |
|
| R92.31 | Mammographic density of right breast | Use when mammogram specifies density in the right breast. |
|
| R92.32 | Mammographic density of left breast | Use when mammogram specifies density in the left breast. |
|
| R92.33 | Mammographic density of bilateral breasts | Use when mammogram specifies density in both breasts. |
|
| R92.34 | Mammographic density of unspecified breast | Use when mammogram indicates density but does not specify laterality. |
|
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
Essential facts and insights about Dense Breast
Primary ICD-10-CM Codes for dense breast
Decision Criteria
documentation Criteria
- Documentation must indicate dense breast without specifying type.
Applicable To
- Dense breast tissue not otherwise specified
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- Mammogram report indicating dense breast tissue without specific type
Code-Specific Risks
- Risk of under-documentation if specific type is not noted
Coding Notes
- Ensure documentation specifies 'dense breast' if using this code.
R92.31 - Mammographic density of right breast
Use when mammogram specifies density in the right breast.
Applicable To
- Right breast density findings
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- Mammogram report indicating density in the right breast
Coding Notes
Laterality must be specified in documentation.
R92.32 - Mammographic density of left breast
Use when mammogram specifies density in the left breast.
Applicable To
- Left breast density findings
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- Mammogram report indicating density in the left breast
Coding Notes
Laterality must be specified in documentation.
R92.33 - Mammographic density of bilateral breasts
Use when mammogram specifies density in both breasts.
Applicable To
- Bilateral breast density findings
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- Mammogram report indicating density in both breasts
Coding Notes
Bilateral specification must be documented.
R92.34 - Mammographic density of unspecified breast
Use when mammogram indicates density but does not specify laterality.
Applicable To
- Unspecified breast density findings
Excludes
- Inconclusive mammogram (R92.2)
Clinical Validation Requirements
- Mammogram report indicating density without laterality
Coding Notes
Ensure documentation specifies 'dense breast' without laterality.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dense Breast to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R92.30.
Impact
Clinical: Inaccurate clinical records, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Always include laterality in mammogram reports, Use R92.30 if laterality is unspecified
Impact
Reimbursement: Incorrect coding may lead to denied claims, Compliance: Non-compliance with updated coding guidelines, Data Quality: Inaccurate data reporting and analysis
Mitigation Strategy
Use R92.3x codes for density findings
Impact
Reimbursement: Claims may be denied due to incomplete documentation, Compliance: Failure to meet coding standards, Data Quality: Inaccurate patient records
Mitigation Strategy
Ensure laterality is documented or use R92.30 if unspecified
Impact
Using R92.2 for density findings instead of R92.3x codes
Mitigation Strategy
Educate coders on new codes and ensure documentation supports code selection
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, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dense Breast
Use these documentation templates to ensure complete and accurate documentation for Dense Breast. These templates include all required elements for proper coding and billing.
Screening Mammogram with Dense Breasts
Specialty: RadiologyRequired Elements
- Indication for screening
- Mammogram findings
- BI-RADS category
- Density type
- Laterality
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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