ICD-10 Coding for Breast Asymmetry(Q83.9, N65.1, N64.89)
Complete ICD-10-CM coding and documentation guide for Breast Asymmetry. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Breast Asymmetry
Q83-Q83.9Primary Range
Congenital malformations of breast
Covers congenital breast asymmetry without surgical history.
Deformity and disproportion of reconstructed breast
Used for asymmetry in reconstructed breasts post-surgery.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Q83.9 | Congenital malformation of breast, unspecified | Use for congenital asymmetry without surgical history. |
|
| N65.1 | Disproportion of reconstructed breast | Use for asymmetry in reconstructed breasts post-surgery. |
|
| N64.89 | Other specified disorders of breast | Use for acquired or idiopathic asymmetry. |
|
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 congenital breast asymmetry
Essential facts and insights about Breast Asymmetry
Primary ICD-10-CM Codes for breast asymmetry
Decision Criteria
clinical Criteria
- Asymmetry present since birth or early development
Applicable To
- Congenital breast asymmetry
Excludes
- Post-surgical asymmetry
- Acquired asymmetry
Clinical Validation Requirements
- Documented history of asymmetry since birth or puberty
- No history of breast surgery
Code-Specific Risks
- Misuse for post-surgical cases
Coding Notes
- Ensure documentation specifies congenital origin.
N65.1 - Disproportion of reconstructed breast
Use for asymmetry in reconstructed breasts post-surgery.
Applicable To
- Asymmetry post-reconstruction
Excludes
- Congenital asymmetry
- Non-reconstructed asymmetry
Clinical Validation Requirements
- Documented history of breast reconstruction
- Imaging showing asymmetry between native and reconstructed breast
Coding Notes
Ensure documentation specifies reconstruction details.
N64.89 - Other specified disorders of breast
Use for acquired or idiopathic asymmetry.
Applicable To
- Acquired breast asymmetry
Excludes
- Congenital asymmetry
- Post-surgical asymmetry
Clinical Validation Requirements
- No congenital or surgical history
- Imaging confirming asymmetry
Coding Notes
Document the absence of congenital or surgical history.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for breast reconstruction follow-up
Z42.1Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Poland syndrome
Q79.8Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Breast Asymmetry to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Q83.9.
Impact
Clinical: Impacts treatment planning, Regulatory: Non-compliance with documentation standards, Financial: Potential claim denials
Mitigation Strategy
Always document the affected side, Use terms like 'left' or 'right'
Impact
Reimbursement: Incorrect DRG assignment, Compliance: Potential audit trigger, Data Quality: Inaccurate clinical data
Mitigation Strategy
Use N64.89 for idiopathic or acquired asymmetry.
Impact
Using codes without proper documentation
Mitigation Strategy
Ensure thorough documentation of clinical scenarios
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 Breast Asymmetry, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Breast Asymmetry
Use these documentation templates to ensure complete and accurate documentation for Breast Asymmetry. These templates include all required elements for proper coding and billing.
Post-Reconstruction Asymmetry
Specialty: Plastic SurgeryRequired Elements
- Patient history of reconstruction
- Imaging findings
- Surgical plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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