Find information on right breast lump diagnosis, including clinical documentation, medical coding, and healthcare resources. Learn about relevant ICD-10 codes, breast imaging procedures, differential diagnoses for breast lumps, and best practices for patient care. Explore resources for healthcare professionals, including diagnostic criteria, treatment options, and follow-up recommendations for patients presenting with a right breast mass. This resource helps with accurate clinical documentation and appropriate medical coding for right breast lump evaluations.
Also known as
Disorders of breast
Covers various breast conditions including lumps and masses.
Abnormal findings of breast
Includes abnormal mammogram and other breast imaging findings.
Benign neoplasm of breast
Specifically for benign breast tumors and growths.
Malignant neoplasm of breast
Used for cancerous breast tumors, if malignancy is suspected.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the right breast lump inflammatory?
Yes
Is it acute mastitis?
No
Is the lump a cyst?
When to use each related code
Description |
---|
Right breast lump |
Fibroadenoma right breast |
Right breast cyst |
Coding right breast lump without laterality specification (e.g., using N10.8 instead of N60.11) leads to inaccurate data and potential claim denials. Crucial for accurate staging and treatment.
Diagnosis of right breast lump without sufficient clinical documentation (physical exam, imaging results) can trigger audits and claim rejections. CDI crucial for complete documentation.
Coding right breast lump as confirmed without definitive diagnostic confirmation (biopsy or other tests) poses compliance risks and potential fraud allegations. CDI should query for clarification.
Patient presents with a palpable right breast lump, prompting evaluation for breast mass, breast nodule, or possible breast cancer. Chief complaint includes discovery of a new lump in the right breast. Onset, duration, and associated symptoms such as breast pain (mastalgia), nipple discharge, skin changes (e.g., dimpling, redness, peau d'orange), or axillary lymphadenopathy were documented. Physical examination revealed a discrete palpable mass in the right breast. The lump's characteristics including size, shape, mobility, tenderness, and location (upper outer quadrant, lower inner quadrant, etc.) were noted. Patient's medical history, including family history of breast cancer, personal history of breast disease, hormonal status, and relevant risk factors, was reviewed. Differential diagnosis includes fibroadenoma, breast cyst, lipoma, and malignancy. Diagnostic workup may include breast imaging such as mammogram, ultrasound, or MRI. Biopsy (e.g., fine needle aspiration, core needle biopsy) may be indicated for definitive diagnosis. Treatment plan will be determined based on diagnostic findings and may involve surgical excision, observation, or other appropriate medical management. Patient education regarding breast self-examination and follow-up care was provided. ICD-10 codes (e.g., N63, D24) and CPT codes for procedures (e.g., 19100, 19200) will be applied as appropriate based on the final diagnosis and management plan.