Nipple discharge
ICD-10 N64.52 is a billable code used to indicate a diagnosis of nipple discharge.
Nipple discharge refers to the secretion of fluid from the nipple, which can occur in both men and women. This condition can be benign or indicative of underlying pathology. Common causes include hormonal changes, benign breast diseases such as fibrocystic changes, and infections like mastitis. Discharge can be unilateral or bilateral and may vary in color and consistency, ranging from clear to bloody. In women, nipple discharge is often associated with conditions such as galactorrhea, which is the inappropriate lactation due to hormonal imbalances, or duct ectasia, where a milk duct beneath the nipple dilates and fills with fluid. Infections like mastitis can lead to purulent discharge and are often accompanied by pain and swelling. Breast imaging, including mammography and ultrasound, is crucial in evaluating nipple discharge, especially when associated with a palpable mass or concerning characteristics. The clinical evaluation should include a thorough history and physical examination to determine the nature of the discharge and guide further diagnostic steps.
Detailed patient history, physical examination findings, and any imaging results.
Patients presenting with unilateral or bilateral nipple discharge, often with associated symptoms like pain or swelling.
Ensure thorough documentation of the nature of the discharge and any relevant hormonal history.
Surgical notes, imaging studies, and pathology reports if biopsies are performed.
Patients with persistent or concerning nipple discharge requiring surgical intervention or further diagnostic evaluation.
Document any surgical findings and correlate with imaging studies to support coding.
When a biopsy is performed due to concerning discharge.
Pathology report and clinical notes indicating the need for biopsy.
Breast surgeons should ensure correlation between imaging and pathology findings.
Document the characteristics of the discharge (color, consistency), whether it is unilateral or bilateral, any associated symptoms, and results from imaging studies.
