Ob-Gyn Coding Alert

Question: My ob-gyn documented “left mastitis,” and someone told me that this isn’t enough documentation. Why not?

Kentucky Subscriber

Answer: If your documentation says the patient has “mastitis,” then you’ll need to query for more information. That’s because mastitis can be of several types; with abscess, without abscess or granulomatous mastitis.

Background: Granulomatous mastitis is a “rare, chronic, inflammatory condition of the breast”. The codes for this type may not be reported often, but you should know that this condition has a “progressive clinical course with multiple recurrences,” according to the ICD-10-CM documentation submitted when the codes were added October 1, 2020. This condition may pose diagnostic and therapeutic challenges for your ob-gyns, which means that the ability to track these cases can help by giving “providers/researchers access to incidence and prevalence data.”

You’ll report this condition with the following codes:

• N61.2 (Granulomatous mastitis)

o N61.20 (Granulomatous mastitis, unspecified breast)

o N61.21 (Granulomatous mastitis, right breast)

o N61.22 (Granulomatous mastitis, left breast)

o N61.23 (Granulomatous mastitis, bilateral breast)

Example: If your ob-gyn treats a patient with granulomatous mastitis of the left breast, you’d report N61.22. If the patient instead has mastitis with or without abscess, you will instead select either N61.0 (Mastitis without abscess) or N61.2 (Abscess of the breast and nipple). Note that neither of these codes describe that breast affected.