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2025 ICD-10-CM code N61.23

Granulomatous mastitis, bilateral breast.

Use N61.23 when both breasts are affected by granulomatous mastitis. Do not use this code if the condition is unilateral; instead, use N61.21 for the right breast or N61.22 for the left breast. Ensure documentation clearly indicates bilateral involvement.

Medical necessity for services related to N61.23 must be established by documenting the signs, symptoms, and diagnostic results consistent with granulomatous mastitis. The documentation should also support the need for the specific treatment or procedure performed.The chosen treatment approach should align with established clinical guidelines for managing this condition.

Diagnosis and treatment of granulomatous mastitis typically falls under the purview of general surgeons, breast surgeons, or physicians specializing in breast health. They are responsible for evaluating the patient's condition, ordering necessary diagnostic tests (such as biopsies), and determining the appropriate course of treatment, which might include medications, surgery, or other interventions.

In simple words: Granulomatous mastitis is a rare, chronic inflammatory condition affecting both breasts. It involves the formation of granulomas, which are clusters of immune cells. This condition is not cancerous.

Granulomatous mastitis, bilateral breast. This condition involves inflammation and granuloma formation in both breasts.

Example 1: A 35-year-old female presents with persistent breast lumps and pain in both breasts. Following a mammogram and biopsy, she receives a diagnosis of granulomatous mastitis, bilateral breast (N61.23)., A 40-year-old female with a history of recurrent breast infections is found to have granulomatous inflammation in both breasts during a routine check-up, confirming bilateral granulomatous mastitis (N61.23)., A patient undergoing treatment for granulomatous mastitis in the right breast develops similar symptoms in the left breast. After further examination, the diagnosis is updated to granulomatous mastitis, bilateral breast (N61.23).

Documentation for N61.23 should include physical exam findings, imaging results (mammography, ultrasound, or MRI), biopsy results confirming granulomatous inflammation, and any relevant medical history. It is crucial to document the involvement of both breasts to support the specific code N61.23

** Granulomatous mastitis can sometimes mimic breast cancer, making accurate diagnosis through biopsy crucial. This condition requires careful management to alleviate symptoms and prevent recurrence. Consulting with a specialist in breast health is recommended for optimal care.

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