Nipple discharge

This code signifies the presence of fluid discharge from the nipple, which is not associated with lactation. It indicates a symptom that requires further investigation to determine its underlying etiology, which can range from benign conditions to more serious pathologies.

Use this code when documentation specifies nipple discharge as a presenting symptom, without a definitive diagnosis of the underlying cause. It is appropriate when the discharge is not related to pregnancy or breastfeeding and the specific characteristics of the discharge (e.g., bloody, serous, purulent) are not yet fully evaluated or are not the primary focus of the encounter.

• Do not use this code if the discharge is explicitly described as an "abnormal finding" in the discharge itself (e.g., abnormal cells), as R89.- would be more appropriate.
• Always seek to code the definitive diagnosis once established, as nipple discharge is a symptom.
• Ensure documentation specifies the laterality (e.g., right, left, bilateral) if known, though this code does not differentiate laterality.