In simple words: An unspecified lump or nodule has been found in the breast.Further investigation is needed to determine the cause, which could range from a harmless cyst to something more serious.

A mass in the mammary gland, either mobile or immobile. Once the mass has reached the size of a small garden pea, it can be detected by palpation. With mammography, a larger number of early breast cancers are being detected since this technique allows detection prior to the point at which the mass can be felt. Breast masses are not always malignant. Benign fibrocystic breast disease is not uncommon. A fine needle biopsy aspiration can distinguish a cystic mass from a solid one.

Example 1: A 45-year-old female presents with a palpable lump in her right breast discovered during a self-exam.The physician documents "Unspecified lump in breast" with code N63 until further diagnostic tests are performed., A 60-year-old female undergoes a routine mammogram which reveals a small, undefined density in the left breast.The radiologist reports "Unspecified breast lump, recommend further evaluation." The referring physician uses N63., A 30-year-old female has a painful lump in her left breast.Ultrasound shows a complex cyst. While the cyst is the likely cause of the lump, the physician initially codes the encounter as N63 until definitive diagnosis after aspiration or biopsy.

Documentation should include location of lump (right, left, axillary tail, unspecified), size if palpable, method of discovery (self-exam, clinical exam, imaging), associated symptoms (pain, nipple discharge), and planned diagnostic workup.Follow-up documentation should describe results of diagnostic studies and definitive diagnosis.

** Excludes1: disorders of breast associated with childbirth (O91-O92)Excludes2: certain conditions originating in the perinatal period (P04-P96), certain infectious and parasitic diseases (A00-B99), complications of pregnancy, childbirth and the puerperium (O00-O9A), congenital malformations, deformations and chromosomal abnormalities (Q00-Q99), endocrine, nutritional and metabolic diseases (E00-E88), injury, poisoning and certain other consequences of external causes (S00-T88), neoplasms (C00-D49), symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94).A 4th digit is required for more specific coding.