Unspecified lump in the right breast
ICD-10 N63.1 is a billable code used to indicate a diagnosis of unspecified lump in the right breast.
N63.1 refers to an unspecified lump located in the right breast. This code is often used when a patient presents with a palpable mass that has not been definitively diagnosed as benign or malignant. The lump may arise from various benign breast diseases, such as fibrocystic changes, fibroadenomas, or lipomas. It can also be associated with conditions like mastitis or breast hypertrophy. The clinical evaluation typically involves a thorough history and physical examination, followed by imaging studies such as mammography or ultrasound to assess the characteristics of the lump. In some cases, a biopsy may be necessary to determine the nature of the lump. Accurate coding requires careful documentation of the clinical findings, imaging results, and any interventions performed. The unspecified nature of this code highlights the importance of further diagnostic workup to rule out malignancy and to provide appropriate management.
Detailed pathology reports and imaging studies.
Patients presenting with breast lumps requiring further evaluation for malignancy.
Ensure clear documentation of the diagnostic process and treatment plan.
Comprehensive imaging reports detailing findings and recommendations.
Imaging studies performed to evaluate breast lumps.
Accurate coding based on imaging findings and correlation with clinical data.
When a lump is excised for further evaluation.
Operative report detailing the procedure and findings.
Ensure that the excision is documented as related to the lump in the right breast.
Document the patient's symptoms, the findings from the physical examination, any imaging studies performed, and the plan for further evaluation or treatment.
