ICD-10 Code for BI-RADS 4
The ICD-10 code for a BI-RADS 4 finding is typically R92.0 (mammographic microcalcification found on diagnostic imaging of breast) or R92.8 (other abnormal and inconclusive findings on diagnostic imaging of breast), depending on the specific imaging finding that prompted the BI-RADS 4 classification.
Understanding BI-RADS 4 Classification
BI-RADS Category 4 designates findings that are suspicious and warrant biopsy, with a malignancy risk ranging from greater than 2% to less than 95% 1. This category covers a wide spectrum of suspicion and does not fulfill typical criteria for malignancy but raises enough concern to recommend tissue diagnosis 2.
Appropriate ICD-10 Coding Based on Imaging Findings
The specific ICD-10 code depends on what imaging abnormality triggered the BI-RADS 4 assessment:
For Microcalcifications
- R92.0 - Mammographic microcalcification found on diagnostic imaging of breast 1
- This is appropriate when suspicious calcifications are the primary finding prompting BI-RADS 4 classification 3
For Masses or Other Findings
- R92.8 - Other abnormal and inconclusive findings on diagnostic imaging of breast 1
- Use this code for suspicious masses, architectural distortion, or other non-calcification findings 4
For Dense Breast Tissue (if relevant)
- R92.2 - Inconclusive mammogram due to dense breasts 5
- This may be used as a secondary code if breast density is a contributing factor
Clinical Management Context
BI-RADS 4 lesions require tissue diagnosis using core needle biopsy (preferred) or needle localization excisional biopsy with specimen radiograph 6. The positive predictive value for malignancy in BI-RADS 4 lesions ranges from 34% to 44.9%, meaning more than half are ultimately benign 7, 8.
Important Coding Considerations
- The ICD-10 code reflects the imaging finding, not the BI-RADS category itself 1
- If biopsy confirms malignancy, the code changes to the specific breast cancer diagnosis (C50.x series) 6
- If biopsy shows benign pathology with imaging concordance, follow-up codes would reflect benign breast conditions 6
Common Pitfalls to Avoid
- Do not use cancer diagnosis codes (C50.x) before histopathologic confirmation, even for BI-RADS 4 or 5 lesions 6
- Ensure pathology-imaging concordance is documented; discordant results require additional tissue sampling and may affect coding 1
- BI-RADS 4 can be subcategorized (4A, 4B, 4C) with increasing malignancy risk (10%, 21%, and 70% respectively), but this does not change the ICD-10 code 3