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v1.0.0
ICD-10 Guide
ICD-10 CodesN64.9

N64.9

Billable

Disorder of breast, unspecified

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

Code Description

ICD-10 N64.9 is a billable code used to indicate a diagnosis of disorder of breast, unspecified.

Key Diagnostic Point:

N64.9 refers to an unspecified disorder of the breast, which encompasses a variety of conditions affecting breast tissue. This code is often used when a patient presents with symptoms such as breast lumps, nipple discharge, or breast pain, but the specific diagnosis has not been determined. Common benign breast diseases include fibrocystic changes, which can cause lumpiness and tenderness, and breast hypertrophy, characterized by excessive breast tissue growth. Mastitis, an infection of the breast tissue, can also present with pain, swelling, and discharge. Imaging studies, such as mammograms or ultrasounds, may be utilized to evaluate breast abnormalities, but in cases where findings are inconclusive or do not lead to a definitive diagnosis, N64.9 may be the appropriate code. Accurate coding is essential for proper treatment and management, as well as for ensuring appropriate reimbursement for healthcare services rendered.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of conditions that can fall under this code
  • Need for thorough documentation to support unspecified diagnosis
  • Potential overlap with other breast-related codes
  • Variability in clinical presentation and imaging findings

Audit Risk Factors

  • Use of unspecified code without adequate documentation
  • Inconsistent clinical findings in the medical record
  • Lack of imaging reports to support diagnosis
  • Failure to follow up on abnormal findings

Specialty Focus

Medical Specialties

Oncology

Documentation Requirements

Detailed history of breast symptoms, imaging results, and any prior treatments.

Common Clinical Scenarios

Patients presenting with breast lumps or abnormal imaging findings requiring further evaluation.

Billing Considerations

Ensure clear documentation of the rationale for using N64.9 when a definitive diagnosis is not established.

Radiology

Documentation Requirements

Comprehensive imaging reports detailing findings and recommendations for further evaluation.

Common Clinical Scenarios

Patients undergoing mammography or ultrasound for breast abnormalities.

Billing Considerations

Radiologists should provide clear descriptions of findings to support coding decisions.

Coding Guidelines

Inclusion Criteria

Use N64.9 When
  • According to the official coding guidelines, N64
  • 9 should be used when the specific disorder of the breast is not documented
  • Coders should ensure that all relevant clinical information is captured to justify the use of this unspecified code

Exclusion Criteria

Do NOT use N64.9 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

77067CPT Code

Mammography, bilateral

Clinical Scenario

Used when a patient presents with breast symptoms requiring imaging.

Documentation Requirements

Mammography report detailing findings and recommendations.

Specialty Considerations

Radiologists should ensure that findings are clearly documented to support coding.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding options, but the use of N64.9 remains relevant for cases where a definitive diagnosis is not established. Coders must be diligent in documenting the clinical rationale for this code.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding options, but the use of N64.9 remains relevant for cases where a definitive diagnosis is not established. Coders must be diligent in documenting the clinical rationale for this code.

Reimbursement & Billing Impact

reimbursement.

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

When should I use N64.9?

Use N64.9 when a patient presents with breast symptoms, and a specific diagnosis has not been established after evaluation and imaging.