2025 ICD-10-CM code N61.0
Mastitis without abscess.
Medical necessity for the diagnosis and treatment of mastitis without abscess is established by the presence of clinical signs and symptoms.The documentation should support the diagnosis and the need for the provided treatment, such as antibiotics or pain management.
Diagnosis and treatment of mastitis without abscess are typically managed by primary care physicians, family medicine practitioners, internists, or general surgeons. In some cases, a specialist like a breast surgeon might be consulted.
In simple words: Inflammation of the breast tissue without the presence of an abscess (a collection of pus).
Mastitis without abscess. This includes infective mastitis (acute) (nonpuerperal) (subacute), mastitis (acute) (nonpuerperal) (subacute) NOS, cellulitis (acute) (nonpuerperal) (subacute) of breast NOS, and cellulitis (acute) (nonpuerperal) (subacute) of nipple NOS.
Example 1: A 35-year-old non-breastfeeding female presents with redness, tenderness, and swelling in her left breast. She has no fever or other systemic symptoms. Upon examination, there is no palpable mass or fluctuance suggestive of an abscess. The diagnosis of mastitis without abscess (N61.0) is made., A 50-year-old male presents with pain and redness around his nipple. He has a history of eczema. After ruling out other causes, the physician diagnoses non-puerperal mastitis without abscess (N61.0)., A 28-year-old female with a history of nipple piercing presents with redness and tenderness around the piercing site. There is no evidence of pus or abscess formation. The physician documents the condition as cellulitis of the nipple without abscess (N61.0).
Documentation should include details of the physical examination findings, such as the presence of redness, tenderness, swelling, warmth, or any nipple discharge. It should also note the absence of fluctuance or a palpable mass, which would suggest an abscess. Patient history, including breastfeeding status, recent trauma, or other relevant medical conditions, should be documented.
** Excludes1: inflammatory carcinoma of breast (C50.9), inflammatory disorder of breast associated with childbirth (O91.-), neonatal infective mastitis (P39.0), thrombophlebitis of breast [Mondor's disease] (I80.8).
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- Specialties:Family Medicine, Internal Medicine, General Surgery, Breast Surgery
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