Breast tenderness, also known as mastodynia or breast pain, can be documented and coded accurately using clinical terminology for healthcare purposes. Learn about the causes, diagnosis, and treatment of breast tenderness, including ICD-10 codes and medical billing guidelines. Find information on managing breast pain and understanding its connection to hormonal changes, menstrual cycles, and other potential factors. This resource provides essential information for healthcare professionals, patients, and medical coders seeking to understand and document breast tenderness effectively.
Also known as
Mastalgia
Pain in the breast, excluding cyclical mastalgia.
Other specified disorders of breast
Covers other breast disorders not classified elsewhere.
Pain in breast
Unspecified pain localized to the breast.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the breast tenderness related to pregnancy or the puerperium?
Yes
Is it during pregnancy?
No
Is the tenderness related to menstruation?
When to use each related code
| Description |
|---|
| Breast pain or discomfort. |
| Cyclical breast pain related to menstruation. |
| Non-cyclical breast pain, not linked to periods. |
Coding for breast tenderness requires specifying right, left, or bilateral. Unspecified laterality leads to coding errors and claim rejections.
Differentiating breast tenderness as a symptom of another condition versus a primary diagnosis impacts code selection and reimbursement.
Documenting and coding the underlying cause of breast tenderness (e.g., hormonal changes, medication) improves coding accuracy and patient care.
Q: How can I differentiate between cyclical mastalgia and non-cyclical breast pain to inform my diagnosis and treatment plan?
A: Differentiating between cyclical and non-cyclical mastalgia is crucial for effective management. Cyclical mastalgia, linked to hormonal fluctuations, typically presents as bilateral, diffuse breast tenderness or pain, often worsening in the luteal phase. Non-cyclical mastalgia is unrelated to the menstrual cycle and can be unilateral, localized, and described as sharp, burning, or aching. Consider a thorough patient history, including menstrual cycle timing, pain characteristics, and location. A physical exam evaluating breast tissue and surrounding structures is essential. Explore how diagnostic imaging, like mammography or ultrasound, can rule out other underlying conditions if indicated by patient presentation or physical exam findings. Learn more about managing cyclical mastalgia with lifestyle modifications, such as reducing caffeine intake, and considering hormonal therapies for severe cases. Non-cyclical mastalgia may require addressing musculoskeletal issues, infections, or other underlying causes. Accurate diagnosis guides appropriate treatment strategies for improved patient outcomes.
Q: When should I consider ordering diagnostic imaging (mammogram, ultrasound) for patients presenting with breast tenderness or mastodynia?
A: While breast tenderness is often benign, particularly cyclical mastalgia, certain clinical presentations warrant further investigation with diagnostic imaging. Consider ordering a mammogram and/or breast ultrasound for patients with focal breast pain, persistent or progressive pain, a palpable lump or mass, skin changes, nipple discharge, or family history of breast cancer. For women over 40, diagnostic imaging is generally recommended for any new-onset breast pain. In younger women, ultrasound is often the preferred initial imaging modality due to its greater sensitivity in dense breast tissue. Remember to factor in patient age, risk factors, and specific symptoms when making imaging decisions. Explore how risk assessment tools can assist in determining the need for further evaluation. Consider implementing clear guidelines for breast pain evaluation in your practice to ensure consistent and evidence-based care. Learn more about interpreting mammogram and ultrasound findings related to breast pain and common differential diagnoses.
Patient presents with complaints of breast tenderness, also known as mastodynia or breast pain. The onset, duration, and character of the breast pain were documented, including location (unilateral or bilateral), radiation, and any associated symptoms such as nipple discharge, skin changes, or palpable masses. The patient's menstrual history, including cycle regularity and timing in relation to the pain, was reviewed to assess for potential cyclical mastalgia. Current medications, including hormonal therapies like oral contraceptives or hormone replacement therapy, were noted. A thorough breast examination was performed, evaluating for breast density, tenderness to palpation, nipple abnormalities, and axillary lymphadenopathy. Differential diagnoses considered included fibrocystic breast changes, mastitis, hormonal fluctuations, and costochondritis. Patient education was provided regarding breast pain management, including supportive bras, over-the-counter pain relievers like ibuprofen or acetaminophen, and lifestyle modifications such as reducing caffeine intake. Further investigation with diagnostic imaging such as mammography or ultrasound may be considered if clinically indicated based on patient history, physical exam findings, or persistent symptoms. Follow-up was scheduled to monitor symptom resolution and discuss further management options if needed. ICD-10 code N26.11 (Pain in breast) is considered for billing and coding purposes.