Experiencing breast discomfort, breast pain, mastodynia, or mastalgia? Find information on diagnosis code B for breast discomfort, including clinical documentation tips for healthcare providers and medical coding guidelines for accurate reporting. Learn about the causes, symptoms, and treatment options for breast pain and mastalgia, and improve your medical record keeping with precise terminology related to breast discomfort and related conditions.
Also known as
Mastalgia
Pain in the breast.
Other specified disorders of breast
Covers other breast disorders not classified elsewhere.
Other specified lumps or masses of the breast
May include breast discomfort associated with palpable changes.
Pain, not elsewhere classified
Can be used if breast pain has no other specific diagnosis.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the breast discomfort associated with pregnancy or lactation?
Yes
Is the discomfort due to engorgement?
No
Is the discomfort cyclical (related to menstrual cycle)?
When to use each related code
| Description |
|---|
| Breast discomfort or pain. |
| Cyclical breast pain related to menstruation. |
| Non-cyclical breast pain, not linked to periods. |
Coding for breast discomfort requires specifying right, left, or bilateral. Unspecified laterality can lead to coding errors and claims rejections. Medical coding guidelines for breast pain require laterality.
Differentiating between breast discomfort as a symptom versus an underlying diagnosis like mastitis or fibrocystic breast changes is crucial for accurate coding and reimbursement. CDI specialists should query for clarity.
If breast discomfort is due to a known condition (e.g., medication side effect), coding the underlying cause is essential for proper healthcare compliance and data analysis. ICD-10 coding for mastodynia requires specificity.
Q: How can I differentiate between cyclical and non-cyclical breast pain to inform my diagnosis and management of mastodynia?
A: Differentiating between cyclical and non-cyclical breast pain is crucial for effective mastodynia management. Cyclical breast pain, often linked to hormonal fluctuations, typically presents bilaterally, with diffuse tenderness in the upper outer quadrants, and may worsen premenstrually. Non-cyclical breast pain, however, is often unilateral, localized, and unrelated to the menstrual cycle. It can be caused by factors such as chest wall pain, musculoskeletal issues, prior trauma, or medications. A thorough patient history, including menstrual history, medication list, and characteristics of the pain (location, duration, quality), aids in distinguishing these types. Physical examination, including palpation of the breasts, axillae, and surrounding areas, helps identify any localized abnormalities. If the pain is localized, consider imaging studies such as mammography or ultrasound. Explore how implementing a symptom diary can help patients track pain patterns and identify potential triggers. For cyclical pain, consider conservative management strategies, such as lifestyle modifications (e.g., supportive bras, dietary changes) or, if severe, hormonal therapies. Non-cyclical pain management depends on the underlying cause and may involve targeted treatments like physical therapy, pain management strategies, or further investigation to rule out other conditions. Learn more about evidence-based guidelines for evaluating and managing breast pain in clinical practice.
Q: When should I consider further investigation (e.g., imaging, biopsy) for breast pain in premenopausal patients with mastalgia, given the potential for anxiety related to breast cancer?
A: While most breast pain (mastalgia) in premenopausal patients is benign, understanding when to pursue further investigation is crucial for both accurate diagnosis and alleviating patient anxiety related to breast cancer. A detailed clinical breast exam is the first step. For patients with focal breast pain, a palpable mass, skin changes, or nipple discharge, imaging studies such as mammography or ultrasound are warranted. Mammography is generally preferred for women over 30, while ultrasound is often used in younger women due to its higher sensitivity in dense breast tissue. If imaging reveals suspicious findings, a biopsy is necessary to obtain a definitive diagnosis. For patients with diffuse, cyclical mastalgia and no other concerning findings, reassurance and conservative management are usually appropriate. However, if the pain is persistent, severe, or unresponsive to initial management, further investigation may still be considered. Consider implementing a shared decision-making approach, discussing the risks and benefits of further investigation with the patient, addressing their concerns, and emphasizing the low likelihood of malignancy in most cases of mastalgia. Explore how risk assessment tools can help stratify patients and guide decision-making regarding further investigation.
Patient presents with breast discomfort, also known as mastodynia or mastalgia. The patient describes the pain as (sharp, dull, aching, burning, throbbing - choose one or describe) and localized to (right breast, left breast, both breasts, specific quadrant - be specific). The onset of breast pain was (gradual, sudden) and began (number) weeks/months ago. The pain is (constant, intermittent) and (cyclical, non-cyclical) in nature. Patient reports (exacerbating factors such as caffeine intake, physical activity, menstrual cycle) and (alleviating factors such as warm compresses, over-the-counter pain relievers - specify medication). The patient denies any palpable lumps, nipple discharge, skin changes, or family history of breast cancer. Physical examination reveals (tenderness to palpation in the affected area, no palpable masses, no skin changes, normal lymph nodes). Differential diagnosis includes cyclical mastalgia, non-cyclical mastalgia, fibrocystic breast changes, costochondritis, and musculoskeletal pain. Assessment includes breast pain, likely (cyclical, non-cyclical) in nature. Plan includes patient education regarding breast pain management, including lifestyle modifications such as (reducing caffeine intake, wearing supportive bras, applying warm compresses). The patient will be instructed on breast self-examination. Consideration for (prescribing NSAIDs, hormonal therapy - be specific if applicable) for pain management if symptoms persist or worsen. Follow-up appointment scheduled in (number) weeks/months to assess symptom improvement and discuss further management options if necessary. ICD-10 code N64.4 (mastalgia) is considered for this encounter.