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Home/Diagnosis/ICD-10 Coding for Bilateral Mastectomy

ICD-10 Coding for Bilateral Mastectomy

Z90.13

Complete ICD-10-CM coding and documentation guide for icd-10 coding for bilateral mastectomy includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Double Mastectomy
Bilateral Breast Removal
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Key Information: ICD-10 Coding for Bilateral Mastectomy

Essential facts and insights about ICD-10 Coding for Bilateral Mastectomy

Use ICD-10 code Z90.13 for acquired absence of bilateral breasts and nipples, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Acquired absence of bilateral breasts and nipples

Billable Code
Z90.13
Billable

Diagnostic Criteria

clinical:
  • • Patient has undergone bilateral mastectomy with no residual breast tissue.
documentation:
  • • Operative report specifies bilateral procedure and absence of breast tissue.

Applicable To

  • • History of bilateral mastectomy

Important Notes

  • • Ensure documentation clearly states 'bilateral mastectomy' and includes dates of procedures.
Ancillary Codes

Additional codes that may be used with this diagnosis

C50.xxx

Malignant neoplasm of breast

Use when documenting active breast cancer requiring mastectomy.

Frequently Asked Questions

What is the ICD-10 code for bilateral mastectomy?

The ICD-10 code for a history of bilateral mastectomy is Z90.13, indicating the acquired absence of both breasts and nipples.

How do you code a bilateral mastectomy with reconstruction?

For bilateral mastectomy with immediate reconstruction, use Z90.13 and CPT code 19307-50, ensuring documentation specifies the reconstruction details.

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