Inconclusive mammogram
ICD-10 R92.2 is a billable code used to indicate a diagnosis of inconclusive mammogram.
An inconclusive mammogram indicates that the results of a mammographic examination are not definitive enough to rule out the presence of breast cancer or other abnormalities. This may occur due to various factors, including dense breast tissue, technical issues during imaging, or the presence of benign lesions that mimic malignancy. Patients may present with no symptoms, or they may report breast pain, palpable masses, or changes in breast appearance. The inconclusive result necessitates further evaluation, which may include additional imaging studies such as ultrasound or MRI, or a biopsy to obtain tissue for histological examination. The clinical context is crucial, as the patient's history, risk factors, and physical examination findings guide the subsequent diagnostic approach. The management of patients with inconclusive mammograms is critical to ensure timely diagnosis and treatment of potential breast cancer.
Thorough documentation of patient history, risk factors, and any physical examination findings related to breast health.
Patients presenting for routine screening who receive an inconclusive result.
Ensure that all follow-up recommendations are documented, including patient education on the significance of the findings.
Detailed documentation of acute presentations, including any breast symptoms and the rationale for imaging.
Patients presenting with breast pain or palpable masses requiring urgent evaluation.
Consider the urgency of follow-up imaging or referral to a specialist based on patient presentation.
Used when performing a mammogram that results in inconclusive findings.
Document the reason for the mammogram and any findings.
Ensure that the mammogram is performed according to guidelines for patients with dense breast tissue.
Document the findings of the mammogram, any symptoms the patient may have, the rationale for the inconclusive result, and the follow-up plan.
