2025 ICD-10-CM code N61.1
Abscess of the breast and nipple.
Medical necessity for treatment of a breast abscess is established by the presence of signs and symptoms, such as pain, swelling, redness, and fluctuance. Imaging studies may be used to confirm the diagnosis and guide treatment. Treatment is necessary to resolve the infection, prevent complications, and alleviate symptoms.
Diagnosis and treatment of breast abscesses are typically managed by primary care physicians, general surgeons, or breast specialists. Clinical responsibility includes performing a physical exam, ordering and interpreting imaging studies (such as ultrasound or mammogram), and determining the appropriate course of treatment. Treatment often involves draining the abscess, prescribing antibiotics, and providing pain management.
In simple words: An abscess is a painful collection of pus that can form in the breast or nipple area. This is often caused by a bacterial infection.
Abscess (acute) (chronic) (nonpuerperal) of areola, Abscess (acute) (chronic) (nonpuerperal) of breast, Carbuncle of breast, Mastitis with abscess.
Example 1: A 35-year-old lactating female presents with a painful, swollen area on her right breast. Upon examination, a fluctuant mass is palpated, and the diagnosis of a breast abscess is made. The abscess is drained, and the patient is started on antibiotics., A 50-year-old non-lactating female presents with redness, tenderness, and swelling in her left breast. An ultrasound reveals a collection of fluid consistent with an abscess. The patient undergoes incision and drainage of the abscess and receives antibiotic therapy., A 28-year-old female with a history of mastitis develops a recurrent breast abscess. After drainage and antibiotic treatment, she is advised on preventive measures to avoid future occurrences.
Documentation should include details of the patient's presenting symptoms, physical exam findings (including location, size, and characteristics of the abscess), results of any imaging studies, procedures performed (e.g., incision and drainage), and prescribed medications. It's also crucial to document the patient's response to treatment and any complications.
** For recurring abscesses, consider investigating underlying causes and providing patient education on preventive measures.
- Specialties:Family Medicine, General Surgery, Breast Surgery
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Independent Clinic