Patient presents with concerns regarding an unspecified breast neoplasm.  Chief complaint includes [insert patient's chief complaint, e.g., palpable lump, breast pain, nipple discharge, skin changes].  Physical examination reveals [describe findings, e.g., size, location, texture, mobility of the mass; presence of lymphadenopathy; nipple inversion or other abnormalities].  Patient history includes [mention relevant medical history, e.g., family history of breast cancer, personal history of breast disease, hormonal factors, age, menopausal status].  Mammography findings are [describe mammographic findings, e.g., BIRADS classification, description of suspicious lesions].  Ultrasound findings are [describe ultrasound findings, e.g., solid vs cystic, margins, vascularity].  Biopsy is recommended to determine the nature of the neoplasm.  Differential diagnosis includes fibroadenoma, cyst, breast cancer, and other benign and malignant breast conditions.  Patient education provided regarding the importance of tissue diagnosis and treatment options.  Plan includes scheduling a biopsy, genetic counseling if indicated, and referral to a breast surgeon for further evaluation and management.  ICD-10 code D24.9 Unspecified neoplasm of breast is documented for medical billing and coding purposes.  Follow-up appointment scheduled for [date] to discuss biopsy results and develop a definitive treatment plan based on the histopathological diagnosis.  The patient understands the plan and all questions were addressed.