ICD-10 Guide

Z12.31

Encounter for screening mammogram for malignant neoplasm of breast

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/12/2025

Code Description

ICD-10 Z12.31 is a billable code used to indicate a diagnosis of encounter for screening mammogram for malignant neoplasm of breast.

Key Diagnostic Point:

Z12.31 is used to indicate an encounter for a screening mammogram aimed at detecting malignant neoplasms of the breast. This preventive measure is crucial for early detection of breast cancer, which significantly improves treatment outcomes and survival rates. Factors influencing the need for screening include age, family history, genetic predisposition, and lifestyle choices. Social determinants of health, such as access to healthcare, socioeconomic status, and education, play a vital role in a patient's likelihood of receiving timely screenings. Preventive care through regular mammograms is essential, especially for women aged 40 and older, as recommended by various health organizations. This code is pivotal in tracking healthcare utilization and outcomes, emphasizing the importance of preventive services in reducing cancer morbidity and mortality.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Need for accurate patient history and risk assessment documentation
Variability in screening guidelines based on age and risk factors
Potential for overlapping diagnoses (e.g., breast pain, abnormal findings)
Importance of distinguishing between screening and diagnostic mammograms

Audit Risk Factors

Inadequate documentation of patient history and risk factors
Misclassification of screening vs. diagnostic mammograms
Failure to document patient education and consent
Inconsistent coding practices across providers

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation must include patient history, risk factors, and consent for screening. The reason for the encounter should be clearly stated.

Common Clinical Scenarios

Routine checkups where screening mammograms are discussed and scheduled, follow-up visits for abnormal mammogram results.

Billing Considerations

Consideration of social determinants such as access to care, insurance status, and education level that may affect screening adherence.

Public Health

Documentation Requirements

Documentation should include population health data, screening rates, and outcomes for community health assessments.

Common Clinical Scenarios

Community outreach programs promoting breast cancer screening, epidemiological studies tracking screening rates.

Billing Considerations

Focus on health disparities and barriers to access that affect screening uptake in different populations.

Coding Guidelines

Inclusion Criteria

Use Z12.31 When

Z codes are used to indicate encounters for preventive services
When coding Z12
31, it should be sequenced as the primary diagnosis when the purpose of the visit is solely for screening
Payer requirements may vary, so it is essential to verify coverage for screening mammograms

Exclusion Criteria

Do NOT use Z12.31 When

No specific exclusions found.

Related CPT Codes

77067CPT Code

Mammography, bilateral, screening

Clinical Scenario

Used in conjunction with Z12.31 for a routine screening mammogram.

Documentation Requirements

Documentation must include the reason for the mammogram and patient consent.

Specialty Considerations

Primary care providers should ensure that patients understand the importance of screening.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding, particularly for screening procedures. Z12.31 provides clear documentation for preventive services, which is essential for quality reporting and reimbursement.

ICD-9 vs ICD-10

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

•
Breast Cancer Screening Guidelines

Coding & Billing References

•
Breast Cancer Screening Guidelines

Frequently Asked Questions

What documentation is required for Z12.31?

Documentation must include the patient's history, risk factors, and the reason for the screening. It should also confirm that the encounter was specifically for a screening mammogram.

ICD-10 Z12.31 is a billable code used to indicate a diagnosis of encounter for screening mammogram for malignant neoplasm of breast.