ICD-10 Coding for Right Breast Mass(N63.12, R92.1)
Complete ICD-10-CM coding and documentation guide for Right Breast Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Breast Mass
N63-N64Primary Range
Disorders of breast
This range includes codes for unspecified breast masses and other breast disorders.
Malignant neoplasm of breast
This range includes codes for malignant breast tumors, which may be relevant if the mass is confirmed as cancerous.
Abnormal and inconclusive findings on diagnostic imaging of breast
This range includes codes for abnormal imaging findings, which are often used in conjunction with breast mass codes.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N63.12 | Unspecified lump in the right breast | Use when a palpable mass is detected in the right breast without a specific diagnosis. |
|
| R92.1 | Mammographic microcalcification found on diagnostic imaging of breast | Use when mammographic microcalcifications are detected in the right breast. |
|
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 breast mass
Essential facts and insights about Right Breast Mass
Primary ICD-10-CM Codes for right breast mass
Decision Criteria
clinical Criteria
- Presence of a palpable mass in the right breast
documentation Criteria
- Lack of specific diagnosis or imaging confirmation
Applicable To
- Palpable mass in right breast
Excludes
- Malignant neoplasm of breast (C50.-)
Clinical Validation Requirements
- Physical examination noting a palpable mass in the right breast
- Documentation of mass location (e.g., quadrant, clock position)
Code-Specific Risks
- Risk of undercoding if malignancy is suspected but not documented.
Coding Notes
- Ensure documentation specifies laterality and mass characteristics.
R92.1 - Mammographic microcalcification found on diagnostic imaging of breast
Use when mammographic microcalcifications are detected in the right breast.
Applicable To
- Microcalcifications on mammogram
Excludes
- Benign neoplasm of breast (D24.-)
Clinical Validation Requirements
- Mammogram report indicating microcalcifications
- BI-RADS category 4 or 5
Coding Notes
Ensure imaging findings are documented clearly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
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 Breast Mass to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N63.12.
Impact
Clinical: May lead to incorrect treatment planning., Regulatory: Increases risk of audit findings., Financial: Can result in claim denials or reduced reimbursement.
Mitigation Strategy
Train staff on the importance of detailed documentation., Use templates that prompt for specific details.
Impact
Reimbursement: Incorrect coding may lead to denied claims or reduced reimbursement., Compliance: Misclassification can result in compliance issues during audits., Data Quality: Affects the accuracy of clinical data and patient records.
Mitigation Strategy
Use N63.12 for unspecified lumps or D24.1 for benign neoplasms.
Impact
Failure to document laterality can lead to incorrect coding and audit findings.
Mitigation Strategy
Implement mandatory fields in EHR for laterality documentation.
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 Breast Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Breast Mass
Use these documentation templates to ensure complete and accurate documentation for Right Breast Mass. These templates include all required elements for proper coding and billing.
Documenting a palpable mass in the right breast
Specialty: RadiologyRequired Elements
- Mass location (quadrant, clock position)
- Size and consistency
- Associated symptoms (e.g., pain, discharge)
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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