Q What is the diagnostic code for breast asymmetry?
A This is a common complaint, especially for patients in whom one breast is a cup size or more smaller than the other. But breast asymmetry isn’t always due to a disease process or congenital deformity—in most people one side of the body is smaller than the other.
The congenital cause is called Poland’s Syndrome. With this condition not only is one breast underdeveloped, but the same-side hand also exhibits anomalies. Clearly, the physician would need to confirm this diagnosis. Code 757.6 (specified anomalies of breast) would work for this syndrome, as well as for cases with documented hypoplasia of the breast.
Another cause of asymmetry might be infection, trauma, or surgery near the developing breast when the patient was a child. For instance, if the patient had a history of a wound and the current breast asymmetry is considered a “late effect” of that wound, you might code 906.0 (late effect of open wound of head, neck, and trunk).
When the cause of the complaint of asymmetry is unknown, consider using 611.79 (other signs and symptoms in breast).
Some women are very sensitive to differences in breast size and want to correct the appearance with a prosthetic bra or surgery. Just make sure that the documentation supports any diagnostic code you use and clearly indicates whether the treatment is cosmetic.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.