ICD-10 Guide

R92.0

Mammographic microcalcification found on diagnostic imaging of breast

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/11/2025

Code Description

ICD-10 R92.0 is a billable code used to indicate a diagnosis of mammographic microcalcification found on diagnostic imaging of breast.

Key Diagnostic Point:

Mammographic microcalcifications are small deposits of calcium that appear as white spots on a mammogram. They are often detected during routine breast screening and can be indicative of various breast conditions, including benign changes or early signs of breast cancer. Microcalcifications can be classified into two categories: benign and suspicious. Benign microcalcifications are typically associated with conditions such as fibrocystic changes or ductal ectasia, while suspicious microcalcifications may warrant further investigation due to their potential association with malignancy. The presence of microcalcifications alone does not indicate cancer; however, their pattern, distribution, and associated findings on imaging are critical in determining the need for additional diagnostic procedures, such as a biopsy. Accurate coding of R92.0 is essential for proper patient management and treatment planning, as it reflects the findings that may lead to further evaluation and intervention.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Differentiating between benign and suspicious microcalcifications
Understanding the implications of associated imaging findings
Navigating documentation requirements for follow-up procedures
Interpreting radiology reports accurately

Audit Risk Factors

Inadequate documentation of the radiologist's interpretation
Failure to specify the type of microcalcifications
Incorrect linkage to follow-up procedures or diagnoses
Misinterpretation of benign versus suspicious findings

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Documentation should include the patient's history, physical examination findings, and any relevant imaging results. Clear notes on the follow-up plan are essential.

Common Clinical Scenarios

Patients presenting for routine screening or with breast complaints where imaging reveals microcalcifications.

Billing Considerations

Consideration of family history of breast cancer and previous breast conditions is crucial for accurate coding.

Emergency Medicine

Documentation Requirements

Acute care documentation must include the reason for imaging, findings, and any immediate interventions or referrals made.

Common Clinical Scenarios

Patients presenting with breast pain or palpable masses that require imaging to assess for microcalcifications.

Billing Considerations

Emergency settings may require expedited follow-up protocols, which should be documented clearly.

Coding Guidelines

Inclusion Criteria

Use R92.0 When

Follow the official ICD
CM coding guidelines, ensuring that the code is used only when microcalcifications are specifically identified on diagnostic imaging
Document the findings and any subsequent procedures performed

Exclusion Criteria

Do NOT use R92.0 When

No specific exclusions found.

Related CPT Codes

77067CPT Code

Mammography, bilateral, including computer-aided detection

Clinical Scenario

Used when performing a mammogram that reveals microcalcifications.

Documentation Requirements

Document the reason for the mammogram and findings.

Specialty Considerations

Radiology must ensure accurate reporting of findings to support coding.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of findings like microcalcifications, improving the accuracy of patient records and treatment plans.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of findings like microcalcifications, improving the accuracy of patient records and treatment plans.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of findings like microcalcifications, improving the accuracy of patient records and treatment plans.

Resources

Clinical References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What should I document when coding R92.0?

Document the findings from the mammogram, any recommendations for follow-up, and the patient's clinical history related to breast health.

ICD-10 R92.0 is a billable code used to indicate a diagnosis of mammographic microcalcification found on diagnostic imaging of breast.