benign breast nodule?

ohn0disaster

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I have a note where the doc wrote, "Benign right breast nodule". Since the word benign is stated, should I be coding this with a benign neoplasm code? If not, should I be using code 611.72 or 793.89? The index points to 793.89 for breast nodule, but I don't believe this fits in this case, since it is for other (abnormal) findings on radiological exam of breast and we've gone further in specifying it is benign.

Any feedback is appreciated. Thanks!
 

terribrown

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First you need to clarify if the dx was based on a mammo or a combination of other diagnostic tests (such as biopsy) or physical exam (palpation).

The code 793.89 would be correct in the case of finding from a mammo.

The fact that the physician states "benign" leads me to believe further testing was done that he/she is referring to, and if documented, I would lean toward the 610.0 Solitary cyst of the breast under the 610 category for Benign Mammory Dysplasias.

If no other documentation to substantiate a "benign" diagnosis, I would further question the physician. If only a physical exam was done, then a breast lump or mass for the 611.72 code should be used.
 

preserene

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Benign Nodule breast:
As for me, the most closer differential Coding diagnosis with this physician's documentation would be: 610.2 Fibroadenosis of breast. It presenst as nodule . the benign nature or nonnoeplastic suites it (until we / or doctors know for sure, the nodule is malignant). A nodule can be anything in nature.The physician documentation also being as Benign, the most favorable diagnosis is 610.2.
 
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