Radiology Coding Alert

Question: How can we code for a ‘focal asymmetry’ found during a mammogram of the breast?

Michigan Subscriber

Answer: You report a focal asymmetry on a mammogram with code 793.82 (Inconclusive mammogram).

What is a focal asymmetry? Your physician will document an asymmetry on a mammogram when there is an increased density in one of the breast on one or both standard mammographic views but there isn’t any evidence of a discrete mass. Both benign and malignant lesions in the breast can lead to asymmetry.

Your physician may document an asymmetry which is stable and remains unchanged over years. This type of asymmetry does not need any further investigations. An asymmetry that is seen on both views of the breast may call for further investigation. Summation shadows are typically seen on one view only and disappear when the view is repeated. Your physician may request an ultrasound if the mammogram shows a summation shadow.