Abscess of the breast and nipple

This code signifies a localized collection of pus within the breast tissue or nipple, typically resulting from a bacterial infection. It presents as a tender, swollen, and often erythematous mass, which may be accompanied by fever and malaise. This condition can occur during lactation (puerperal) or independently (nonpuerperal).

Apply this code when documentation clearly indicates a diagnosis of a breast or nipple abscess, confirmed by physical examination findings such as a palpable fluctuant mass, erythema, and pain. It is appropriate for both lactational and non-lactational abscesses. Supporting documentation should include physician notes detailing the location, size, and clinical presentation of the abscess.

• Differentiate from mastitis without abscess formation; mastitis codes (e.g., N61.0) should be used if no localized pus collection is identified.
• Specify laterality (e.g., N61.11 for right breast, N61.12 for left breast, N61.13 for bilateral) when documented.
• Consider an additional code for the underlying infectious organism (e.g., B95.6 for Staphylococcus aureus) if identified and documented.