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N63.10
ICD-10-CM
Right Breast Lump

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

Lump in Right Breast
Right Breast Mass

Diagnosis Snapshot

Key Facts
  • Definition : A palpable mass or abnormal area of thickening in the right breast tissue.
  • Clinical Signs : May include breast pain, nipple discharge, skin changes, or changes in breast size or shape.
  • Common Settings : Primary care, breast clinic, imaging center (mammogram, ultrasound).

Related ICD-10 Code Ranges

Complete code families applicable to AAPC N63.10 Coding
N60-N64

Disorders of breast

Covers various breast conditions including lumps and masses.

R92

Abnormal findings of breast

Includes abnormal mammogram and other breast imaging findings.

D24

Benign neoplasm of breast

Specifically for benign breast tumors and growths.

C50

Malignant neoplasm of breast

Used for cancerous breast tumors, if malignancy is suspected.

Code-Specific Guidance

Decision Tree for

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?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right breast lump
Fibroadenoma right breast
Right breast cyst

Documentation Best Practices

Documentation Checklist
  • Right breast lump location, size, shape
  • Palpation findings: tenderness, mobility, consistency
  • Associated symptoms: nipple discharge, skin changes
  • Imaging results: mammography, ultrasound, MRI findings
  • Diagnosis codes: N63, C50 (if applicable)

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    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.

  • Lack of Clinical Support

    Diagnosis of right breast lump without sufficient clinical documentation (physical exam, imaging results) can trigger audits and claim rejections. CDI crucial for complete documentation.

  • Unconfirmed Diagnosis

    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.

Mitigation Tips

Best Practices
  • Thorough breast exam coding: ICD-10 N63, laterality, specifics
  • Document lump details: size, shape, location for accurate CDI
  • Image guidance for biopsies: Compliance, proper CPT coding
  • Follow established protocols for diagnosis, ensure healthcare compliance
  • Timely follow-up & documentation: Improve patient outcomes, risk adjustment

Clinical Decision Support

Checklist
  • Confirm laterality: Right breast documented?
  • Physical exam: Lump characteristics & location noted?
  • Imaging: Mammogram/ultrasound ordered & results reviewed?
  • Biopsy considered/performed? Pathology results documented?
  • Diagnosis ICD-10 codes (e.g., N60.1, N63) assigned?

Reimbursement and Quality Metrics

Impact Summary
  • Right Breast Lump: ICD-10 N63, CPT 19125 (biopsy), accurate coding maximizes reimbursement.
  • Quality metrics: Timely diagnosis, appropriate imaging (mammography, ultrasound), biopsy lead time affects quality reporting.
  • Denial risk reduced with proper documentation linking lump evaluation, imaging, and biopsy procedure.
  • Patient experience: Clear communication, efficient scheduling minimize anxiety related to breast lump evaluation.

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.

Quick Tips

Practical Coding Tips
  • Code N63, specify location
  • Rule out malignancy, document
  • Document lump characteristics
  • Consider imaging findings, code
  • Biopsy? Code procedure, results

Documentation Templates

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.