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ICD-10 Guide
ICD-10 CodesR92.311

R92.311

Mammographic fatty tissue density, right breast

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R92.311 is a billable code used to indicate a diagnosis of mammographic fatty tissue density, right breast.

Key Diagnostic Point:

Mammographic fatty tissue density refers to the composition of breast tissue as seen on a mammogram. In this context, it indicates that the right breast has a predominance of fatty tissue, which can be a normal finding in women, particularly those who are older or have a higher body mass index. Fatty tissue density can affect the sensitivity of mammograms, as denser breast tissue may obscure lesions or abnormalities. While fatty tissue density itself is not a disease, it is an important factor in breast cancer screening and risk assessment. Clinicians may monitor changes in breast density over time, as increased density can be associated with a higher risk of breast cancer. It is crucial for healthcare providers to document any relevant clinical findings, patient history, and risk factors when coding this condition to ensure accurate diagnosis and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in breast tissue density among patients
  • Need for correlation with mammography reports
  • Potential for misinterpretation of findings
  • Documentation of patient history and risk factors

Audit Risk Factors

  • Inadequate documentation of mammography findings
  • Failure to correlate with clinical symptoms or history
  • Misuse of the code for non-fatty tissue density findings
  • Inconsistent coding practices across providers

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Documentation should include patient history, risk factors for breast cancer, and any previous mammography results.

Common Clinical Scenarios

Routine screening mammograms, follow-up on previous findings, and risk assessment in patients with family history.

Billing Considerations

Consideration of hormonal factors and lifestyle choices that may affect breast density.

Emergency Medicine

Documentation Requirements

Acute care documentation should include the reason for the mammogram, any acute symptoms, and relevant patient history.

Common Clinical Scenarios

Patients presenting with breast pain or palpable masses requiring urgent evaluation.

Billing Considerations

Emergency settings may require expedited reporting and follow-up on abnormal findings.

Coding Guidelines

Inclusion Criteria

Use R92.311 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code is used in conjunction with appropriate clinical documentation and mammography reports
  • Ensure that the code reflects the specific breast side and any relevant findings

Exclusion Criteria

Do NOT use R92.311 When
No specific exclusions found.

Related CPT Codes

77067CPT Code

Mammography, bilateral, including computer-aided detection

Clinical Scenario

Used for routine screening in patients with fatty tissue density.

Documentation Requirements

Mammography report must indicate findings and any recommendations for follow-up.

Specialty Considerations

Documentation should reflect the patient's risk factors and any previous imaging results.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of breast density findings, improving the accuracy of data collection and patient management. R92.311 provides clarity in documenting fatty tissue density, which is essential for risk assessment and screening protocols.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of breast density findings, improving the accuracy of data collection and patient management. R92.311 provides clarity in documenting fatty tissue density, which is essential for risk assessment and screening protocols.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of breast density findings, improving the accuracy of data collection and patient management. R92.311 provides clarity in documenting fatty tissue density, which is essential for risk assessment and screening protocols.

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 does R92.311 indicate?

R92.311 indicates that a mammogram has shown fatty tissue density in the right breast, which is a normal finding but requires monitoring for any changes.