Radiology Coding Alert

Question: We have a patient seen for a high-risk breast magnetic resonance imaging (MRI) scan screening due to a family history of breast cancer. The impression states dense breasts. Should I code this with a screening code in addition to the dense breasts and family history codes?

New York Subscriber

Answer: You should reserve code Z12.31 (Encounter for screening mammogram for malignant neoplasm of breast) for screening mammograms. However, ICD-10-CM guidelines instruct that you should report a screening code as the first-listed diagnosis when the indication does not reveal and true sign or symptom. This means you will report Z12.39 (Encounter for other screening for malignant neoplasm of breast) as the first-listed diagnosis. Next, you will report R92.2 (Inconclusive mammogram) and Z80.3 (Family history of malignant neoplasm of breast) as secondary diagnoses.

Despite the fact that the code description for R92.2 describes the results of a mammogram, you should not be deterred from attaching this diagnosis code to a breast MRI CPT^® code, such as 77049 (Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral). In fact, you’ll find R92.2 under the ICD-10-CM coding crosswalk for CPT^® code 77049 in addition to other breast MRI CPT^® codes.