ICD-10 Coding for Right Axillary Mass(R22.31, N63.31, C77.3)
Complete ICD-10-CM coding and documentation guide for Right Axillary Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Axillary Mass
R22.3-R22.39Primary Range
Localized swelling, mass and lump, upper limb
Covers non-breast origin axillary masses in the upper limb.
Unspecified lump in axillary tail of breast
Used when the mass is in the axillary tail of the breast.
Secondary malignant neoplasm of axillary lymph nodes
Applicable for metastatic cancer in axillary lymph nodes.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R22.31 | Localized swelling, mass and lump, right upper limb | Use when the mass is in the axilla proper without breast tissue involvement. |
|
| N63.31 | Unspecified lump in axillary tail of right breast | Use when the mass is in the axillary tail of the breast. |
|
| C77.3 | Secondary malignant neoplasm of axillary lymph nodes | Use when biopsy confirms metastatic cancer in axillary lymph nodes. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for right axillary mass
Essential facts and insights about Right Axillary Mass
Primary ICD-10-CM Codes for right axillary mass
Decision Criteria
clinical Criteria
- Mass is located in the axilla without breast tissue involvement.
coding Criteria
- No breast tissue involvement confirmed by imaging.
Applicable To
- Non-breast origin axillary mass
Clinical Validation Requirements
- Imaging confirming non-breast origin
- Physical exam showing superficial mass
Code-Specific Risks
- Misclassification if breast tissue involvement is not ruled out
Coding Notes
- Ensure imaging confirms non-breast origin to avoid misclassification.
N63.31 - Unspecified lump in axillary tail of right breast
Use when the mass is in the axillary tail of the breast.
Applicable To
- Mass in axillary tail of breast
Excludes
- Non-breast axillary mass (R22.31)
- Metastatic lymph node (C77.3)
Clinical Validation Requirements
- Mammography/ultrasound showing continuity with breast parenchyma
Coding Notes
Document imaging findings to confirm breast tissue involvement.
C77.3 - Secondary malignant neoplasm of axillary lymph nodes
Use when biopsy confirms metastatic cancer in axillary lymph nodes.
Applicable To
- Metastatic cancer in axillary lymph nodes
Excludes
- Primary breast cancer (C50.911)
Clinical Validation Requirements
- Biopsy confirming metastatic cancer
Coding Notes
Sequence primary cancer code before C77.3.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right Axillary Mass to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R22.31.
Impact
Clinical: Ambiguity in patient records., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always specify right or left in documentation.
Impact
Reimbursement: Incorrect DRG assignment may affect payment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use N63.31 if imaging shows breast tissue involvement.
Impact
Lack of imaging documentation for axillary masses.
Mitigation Strategy
Ensure all imaging findings are documented in the patient's record.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Right Axillary Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Axillary Mass
Use these documentation templates to ensure complete and accurate documentation for Right Axillary Mass. These templates include all required elements for proper coding and billing.
Surgical Note for Biopsy
Specialty: SurgeryRequired Elements
- Location of mass
- Imaging correlation
- Procedure details
- Findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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