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N62
ICD-10-CM
Large Breast

Find comprehensive information on large breasts, including macromastia, gigantomastia, breast hypertrophy, and related clinical documentation for accurate medical coding. Learn about diagnosis, treatment options, and ICD-10 codes for breast hyperplasia and other relevant terms used in healthcare settings. This resource provides valuable insights for medical professionals seeking information on large breast size and its associated medical terminology.

Also known as

Breast Hypertrophy
Macromastia

Diagnosis Snapshot

Key Facts
  • Definition : Breast size significantly exceeding average, potentially causing physical discomfort.
  • Clinical Signs : Back pain, neck pain, shoulder grooving, skin irritation, posture issues.
  • Common Settings : Plastic surgery consultations, primary care physician visits, physical therapy.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC N62 Coding
N62

Hypertrophy of breast

Covers excessive breast growth, including macromastia and gigantomastia.

Q83

Congenital malformations of breast

May include overdevelopment as a congenital anomaly, though less common.

R39.8

Other symptoms and signs involving skin and subcutaneous tissue

Can be used for unspecified breast enlargement if other codes don't fit.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the large breast due to hypertrophy of breast tissue?

  • Yes

    Is it unilateral?

  • No

    Is it due to fat deposition?

Documentation Best Practices

Documentation Checklist
  • Large breast diagnosis ICD-10 code
  • Symptoms impacting daily life (pain, posture)
  • Measurements: bust, underbust, asymmetry
  • Patient reported symptoms and history
  • Treatment plan discussion and options

Mitigation Tips

Best Practices
  • Code accurately: N62, plus laterality & other specifics
  • Document breast size impact on exams/imaging
  • Address patient concerns, document QoL impact
  • Assess/document any functional limitations
  • Ensure proper bra fitting education/referral

Clinical Decision Support

Checklist
  • Confirm breast hypertrophy diagnosis: ICD-10 N62.1, document symptoms.
  • Exclude gigantomastia, pseudogynecomastia: review patient history, physical exam.
  • Assess impact on patient function: document posture, shoulder pain, skin changes.
  • Consider imaging: mammography, MRI if indicated, document findings for medical necessity.

Reimbursement and Quality Metrics

Impact Summary
  • Large Breast diagnosis reimbursement impacts depend on accurate ICD-10 coding (N62) and proper documentation for medical necessity justifying procedures like reduction mammoplasty.
  • Coding errors for Large Breast (N62) can lead to claim denials, impacting hospital revenue cycle management and reimbursement rates.
  • Quality metrics for Large Breast patients may include patient-reported outcome measures (PROMs) assessing pain, function, and quality of life after interventions.
  • Accurate coding and documentation for Large Breast support appropriate hospital reporting for surgical volumes, complications, and resource utilization.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Frequently Asked Questions

Common Questions and Answers

Q: What are the evidence-based best practices for managing macromastia in patients experiencing significant physical symptoms and functional limitations?

A: Managing macromastia with significant physical symptoms and functional limitations requires a multi-faceted approach. Evidence-based best practices emphasize a thorough patient history, including detailed documentation of symptom duration, severity (e.g., pain scales, interference with daily activities), and associated psychosocial impacts. Physical examination should assess breast size, shape, skin changes, and postural issues. Imaging studies (mammography, ultrasound) are necessary for breast cancer screening prior to any intervention. Conservative management options like supportive bras, physical therapy for posture correction, and pain management strategies (NSAIDs, topical analgesics) can be initially considered. However, for significant functional impairment and persistent symptoms, breast reduction surgery remains the most effective intervention. Pre-operative assessment should include a comprehensive evaluation of cardiovascular and respiratory health, as well as consideration of patient-specific risk factors for surgical complications. Explore how patient-specific factors can influence surgical decision-making and post-operative outcomes in macromastia management.

Q: How can I differentiate between macromastia and other breast conditions like gigantomastia or breast hypertrophy in clinical practice, and what are the key diagnostic considerations?

A: Differentiating macromastia, gigantomastia, and breast hypertrophy hinges on understanding their defining characteristics. Macromastia refers to excessively large breasts causing physical symptoms like back pain, neck pain, intertrigo, or bra strap grooving. Gigantomastia represents a more extreme overgrowth, often rapid and associated with hormonal fluctuations (e.g., pregnancy, puberty, medications), potentially involving significant asymmetry and skin changes. Breast hypertrophy, a broader term, encompasses various forms of breast enlargement, not always reaching the magnitude of macromastia or gigantomastia. Diagnostic considerations include a detailed patient history focusing on symptom onset, duration, associated factors, and family history. Clinical examination evaluates breast size, symmetry, and skin condition. Imaging (mammography, ultrasound, MRI if indicated) aids in ruling out underlying pathologies. Precise diagnosis informs appropriate management strategies, which may range from conservative measures for macromastia to surgical intervention for gigantomastia. Consider implementing a standardized diagnostic approach for breast enlargement conditions to ensure accurate and consistent patient care. Learn more about the nuanced differences in clinical presentation and management strategies for these related conditions.

Quick Tips

Practical Coding Tips
  • Code N62 for hypertrophy
  • Laterality matters: use modifiers
  • Document breast size/measurements
  • Exclude pregnancy-related changes
  • Consider macromastia code

Documentation Templates

Patient presents with complaint of large breasts, medically termed macromastia or gigantomastia, causing significant physical and psychological distress.  Symptoms include chronic neck pain, back pain, shoulder pain, intertrigo, bra strap grooving, postural issues, and difficulty with physical activity.  Physical examination reveals breast hypertrophy exceeding normal proportions, potentially impacting respiratory function and causing skin irritation beneath the breasts.  Patient reports limitations in daily activities and social interactions due to breast size.  Differential diagnosis includes pseudogynecomastia, lipomastia, and other causes of breast enlargement.  Assessment suggests breast reduction surgery, also known as reduction mammoplasty, as a potential treatment option to alleviate symptoms, improve quality of life, and address functional limitations.  Discussion included risks and benefits of surgery, alternative treatments such as supportive bras and weight management, and the potential for insurance coverage based on medical necessity.  Patient education provided on pre-operative preparation, post-operative care, and expected outcomes.  Referral to plastic surgery specialist initiated for further consultation and surgical evaluation.  ICD-10 code N62.89 (other specified disorders of breast) and CPT codes for reduction mammoplasty (e.g., 19318) are considered for documentation and billing purposes.  Follow-up scheduled to discuss surgical plan and address any further concerns.
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