Unspecified benign mammary dysplasia of unspecified breast

This code describes a non-cancerous, abnormal development or growth of breast tissue where the specific type of dysplasia and the affected breast are not documented. It indicates a general, benign architectural distortion or cellular change within the mammary gland.

Use this code when the medical record clearly states "benign mammary dysplasia" but lacks further specificity regarding the histological type (e.g., fibrocystic changes, adenosis) or laterality (left, right, bilateral). This code is appropriate when a definitive diagnosis of benign breast disease is made, but the physician's documentation does not provide enough detail for a more specific ICD-10-CM code.

• Avoid using this code if the documentation specifies a particular type of benign mammary dysplasia (e.g., fibrocystic disease, adenosis), as more specific codes exist.
• Query the provider for laterality (left, right, bilateral) if not documented, as this can lead to a more precise code.
• This code should only be used when no further information is available to classify the benign mammary dysplasia more accurately.