AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Quarter 4; New/Revised ICD-10-CM Diagnosis Codes
Lump in Breast
When coding the diagnosis of breast conditions and the physician documents the location in terms such as positions on a clock, is it appropriate to code to the associated breast quadrant? For example, based on the statement “lump in the right breast at 11 o’clock,” is it appropriate to assign code N63.11 , Unspecified lump in the right breast, upper-outer quadrant of right female breast, if the physician has documented 11 o’clock in lieu of upper-outer quadrant? ...
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Article Overview
This article explains an ICD-10-CM update affecting coding for breast lumps and reviews how documentation of breast location may be interpreted when providers use clock-position language. It is aimed at coders, compliance staff, and facilities that develop internal documentation guidelines for breast diagnosis reporting. The discussion focuses on the scope of the diagnosis category, laterality and location specificity, and the relationship between facility-level guidance and official coding guidelines.
Why This Topic Matters
Breast lump documentation is common in clinical practice, and accurate location-specific diagnosis reporting affects code selection and data quality. The article helps readers understand what level of documentation may support more specific ICD-10-CM reporting and how facilities may approach internal guidance without conflicting with official rules.
What You Will Learn
- How this ICD-10-CM diagnosis category has been expanded for greater location specificity
- How clock-position documentation is discussed in relation to breast quadrants
- Why facilities may consider internal guidance for documenting breast lump location
- How facility policies relate to official ICD-10-CM coding guidance
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Health information management staff
- Facility policy developers
Codes Discussed
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