ICD-10 Coding for Breast Benign Cyst(N60.09, N60.01, N60.02)
Complete ICD-10-CM coding and documentation guide for Breast Benign Cyst. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Breast Benign Cyst
N60.0-N60.9Primary Range
Benign mammary dysplasia
This range includes codes for benign cysts and other non-neoplastic breast conditions.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N60.09 | Solitary cyst of unspecified breast | Use when a simple cyst is confirmed by imaging without solid components. |
|
| N60.01 | Solitary cyst of right breast | Use when a simple cyst is confirmed in the right breast. |
|
| N60.02 | Solitary cyst of left breast | Use when a simple cyst is confirmed in the left 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 breast benign cyst
Essential facts and insights about Breast Benign Cyst
Primary ICD-10-CM Codes for breast benign cyst
Decision Criteria
clinical Criteria
- Ultrasound shows anechoic, thin-walled cyst with posterior enhancement.
documentation Criteria
- Include imaging findings and absence of solid components.
Applicable To
- Simple breast cyst
Excludes
- Benign neoplasm of breast (D24)
Clinical Validation Requirements
- Anechoic appearance on ultrasound
- Smooth margins
- No solid components
Code-Specific Risks
- Misclassification as a neoplasm
- Incorrect laterality documentation
Coding Notes
- Ensure imaging confirms the cyst is simple and benign.
N60.01 - Solitary cyst of right breast
Use when a simple cyst is confirmed in the right breast.
Applicable To
- Simple cyst of right breast
Excludes
- Benign neoplasm of breast (D24)
Clinical Validation Requirements
- Anechoic appearance on ultrasound
- Smooth margins
- No solid components
Coding Notes
Ensure imaging confirms the cyst is simple and benign.
N60.02 - Solitary cyst of left breast
Use when a simple cyst is confirmed in the left breast.
Applicable To
- Simple cyst of left breast
Excludes
- Benign neoplasm of breast (D24)
Clinical Validation Requirements
- Anechoic appearance on ultrasound
- Smooth margins
- No solid components
Coding Notes
Ensure imaging confirms the cyst is simple and benign.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Inconclusive mammogram
R92.2Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Breast Benign Cyst to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N60.09.
Impact
Clinical: May lead to unnecessary follow-up procedures., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to insufficient documentation.
Mitigation Strategy
Always include BI-RADS category in imaging reports., Train staff on the importance of complete documentation.
Impact
Reimbursement: Incorrect coding may lead to denied claims or reduced reimbursement., Compliance: Failure to comply with coding guidelines can result in audits., Data Quality: Inaccurate data entry affects clinical records and research data.
Mitigation Strategy
Use N60.01 for right breast or N60.02 for left breast when laterality is documented.
Impact
Using N60.09 when laterality is documented can trigger audits.
Mitigation Strategy
Verify documentation for laterality before coding.
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 Benign Cyst, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Breast Benign Cyst
Use these documentation templates to ensure complete and accurate documentation for Breast Benign Cyst. These templates include all required elements for proper coding and billing.
Imaging and diagnosis of a simple breast cyst
Specialty: RadiologyRequired Elements
- Patient demographics
- Breast laterality
- Ultrasound findings
- BI-RADS category
- Follow-up recommendations
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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