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ICD-10 Guide
ICD-10 CodesN63.31

N63.31

Billable

Unspecified lump in axillary tail of the right breast

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/18/2025

Code Description

ICD-10 N63.31 is a billable code used to indicate a diagnosis of unspecified lump in axillary tail of the right breast.

Key Diagnostic Point:

The ICD-10 code N63.31 refers to an unspecified lump located in the axillary tail of the right breast. This condition is often associated with benign breast diseases, which can include fibrocystic changes, fibroadenomas, or lipomas. The axillary tail, also known as the axillary process or tail of Spence, is an extension of breast tissue that extends into the axilla (armpit) area. Patients may present with a palpable mass, which can be asymptomatic or associated with discomfort. Differential diagnoses may include mastitis, which is an infection of the breast tissue, or breast hypertrophy, characterized by excessive breast tissue growth. Imaging studies such as mammography or ultrasound are typically employed to evaluate the lump, assess its characteristics, and rule out malignancy. Nipple discharge may also be evaluated if present, as it can indicate underlying pathology. Accurate coding requires thorough documentation of the lump's characteristics, patient history, and any imaging results to ensure appropriate management and follow-up.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in lump characteristics (size, consistency, tenderness)
  • Need for imaging studies to confirm diagnosis
  • Differentiation between benign and malignant conditions
  • Potential for co-existing conditions (e.g., mastitis, hypertrophy)

Audit Risk Factors

  • Inadequate documentation of lump characteristics
  • Failure to include imaging results in the medical record
  • Misclassification of benign versus malignant conditions
  • Lack of follow-up documentation for ongoing management

Specialty Focus

Medical Specialties

Oncology

Documentation Requirements

Detailed imaging reports, pathology results, and treatment plans.

Common Clinical Scenarios

Evaluation of breast lumps for potential malignancy, follow-up after biopsy.

Billing Considerations

Ensure clear documentation of any findings that may indicate cancer.

Radiology

Documentation Requirements

Comprehensive imaging reports detailing findings and recommendations.

Common Clinical Scenarios

Breast ultrasound or mammography for evaluation of palpable lumps.

Billing Considerations

Accurate descriptions of imaging findings are crucial for coding.

Coding Guidelines

Inclusion Criteria

Use N63.31 When
  • According to the official coding guidelines, N63
  • 31 should be used when a lump in the axillary tail of the right breast is documented without further specification
  • Coders should ensure that the documentation supports the diagnosis and that any imaging studies are referenced

Exclusion Criteria

Do NOT use N63.31 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

76098CPT Code

Breast ultrasound

Clinical Scenario

Used to evaluate a palpable lump in the axillary tail of the right breast.

Documentation Requirements

Include indication for ultrasound and findings.

Specialty Considerations

Radiologists should provide detailed descriptions of the lump.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specificity in coding breast conditions, including the ability to differentiate between lumps in various locations, which aids in better patient management and tracking of breast health.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specificity in coding breast conditions, including the ability to differentiate between lumps in various locations, which aids in better patient management and tracking of breast health.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specificity in coding breast conditions, including the ability to differentiate between lumps in various locations, which aids in better patient management and tracking of breast health.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What should be documented when coding N63.31?

Documentation should include the characteristics of the lump, any associated symptoms, imaging results, and the clinical decision-making process.