Mammographic heterogeneous density, right breast
ICD-10 R92.331 is a billable code used to indicate a diagnosis of mammographic heterogeneous density, right breast.
Mammographic heterogeneous density refers to the presence of varying densities in breast tissue as observed on a mammogram. This finding indicates that the breast contains both dense and fatty tissues, which can complicate the interpretation of mammograms. Heterogeneous density is significant because it may obscure the visibility of lesions or abnormalities, potentially leading to missed diagnoses of breast cancer. The right breast is specified in this code, indicating that the findings are localized. Common symptoms associated with this finding may include palpable masses or changes in breast shape or size, although many patients may be asymptomatic. The clinical significance of heterogeneous density lies in its association with an increased risk of breast cancer, necessitating further evaluation through additional imaging or biopsy. Regular screening and follow-up are crucial for women with this finding to ensure early detection of any potential malignancies.
Documentation should include a thorough history of breast health, any symptoms reported by the patient, and results from previous mammograms.
Patients presenting for routine screening or follow-up after previous abnormal findings.
Consideration of family history of breast cancer and other risk factors is essential for accurate coding.
Acute care documentation should include any presenting symptoms, imaging results, and immediate management plans.
Patients presenting with breast pain or palpable masses requiring urgent evaluation.
Emergency settings may require expedited imaging and documentation of findings for timely intervention.
Used when performing a mammogram that reveals heterogeneous density.
Document the reason for the mammogram and any findings.
Ensure that the mammography report is available for accurate coding.
Heterogeneous density indicates that there are areas of varying density in the breast tissue, which can make it more challenging to detect abnormalities.
