Ob-Gyn Coding Alert

If your ob-gyn documents a specific type of lump, code that instead.

A patient may discover a lump within the breast tissue during her monthly self breast exam. Most lumps are not cancer but do represent changes within the breast tissue.

ICD-9-CM Code:

611.72, Lump or mass in breast

ICD-10-CM Code:

 N63, Unspecified lump in breast

This is a one-to-one correlation. Code 611.72 will become N63 when October 1, 2015 hits.

Documentation: If your physician documents a lump in the breast, then you should report it. Keep in mind you might see four kinds: cysts, fibroadenomas, pseudolumps, and cancer. If your physician documents a specific type, then you may code something other than N63. 

Check your Alphabetic Index:

Breast —see also condition

- buds E30.1
- - in newborn P96.89
- dense R92.2
- nodule N63

Mass

- breast N63

Nodule(s), nodular

- breast NEC N63

Swelling (of) 

- breast N63

Coding tips: Although N63 is only three characters, you don’t need to add any more characters to this.