Find comprehensive information on mastitis diagnosis, including clinical documentation, ICD-10 codes (N61, O91.0, P39.0), SNOMED CT concepts, and medical coding guidelines. Learn about symptoms, treatment, and lactation mastitis for accurate healthcare records and billing. Explore resources for healthcare professionals on diagnosing puerperal mastitis and breast abscess related to mastitis. This resource supports proper clinical documentation and coding for mastitis in medical records.
Also known as
Mastitis
Inflammation of the breast tissue, often related to breastfeeding.
Infections of breast associated with childbirth
Infections in the breast occurring during the postpartum period.
Infections specific to the perinatal period
Various infections affecting newborns or mothers around childbirth.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the mastitis puerperal (related to childbirth)?
When to use each related code
| Description |
|---|
| Breast inflammation, usually infection. |
| Breast abscess |
| Mammary duct ectasia |
Coding mastitis without specifying right, left, or bilateral breast can lead to rejected claims and inaccurate data reporting. CDI should query for laterality.
Incorrectly coding lactation status (puerperal vs. non-puerperal) impacts severity and treatment. CDI should clarify documentation.
Differentiating between infective and non-infective mastitis is crucial for accurate coding and treatment. Vague documentation poses audit risks.
Patient presents with symptoms consistent with mastitis. Chief complaint includes breast pain, tenderness, swelling, and redness, possibly accompanied by fever, chills, and flu-like symptoms. Area of inflammation and induration may be palpable on physical examination. Patient reports breastfeeding or recent cessation of breastfeeding, though mastitis can occur in non-lactating women as well. Possible contributing factors include nipple trauma, milk stasis, blocked milk duct, or bacterial infection, most commonly Staphylococcus aureus. Differential diagnosis includes breast abscess, plugged duct, galactocele, and inflammatory breast cancer. Diagnostic workup may include breast ultrasound to rule out abscess formation. Treatment plan includes frequent breastfeeding or milk expression, warm compresses, pain management with ibuprofen or acetaminophen, and antibiotic therapy targeting Staphylococcus aureus coverage, such as dicloxacillin or cephalexin. Patient education provided regarding proper breastfeeding techniques, breast hygiene, and complete antibiotic course adherence. Follow-up appointment scheduled to assess treatment response and resolution of symptoms. ICD-10 code: O91. Lactation status documented. Severity of mastitis noted (e.g., mild, moderate, severe).