ICD-10 - Asymmetry Not Following Reconstruction

Question:

Looking for some ICD-10 advice from KZA. In instances in which a patient presents to our practice for breast asymmetry following lumpectomy, and no reconstruction has been performed. Is N65.1 appropriate to report? If not, what is the proper ICD-10 code?

Answer:

Great question! Since no reconstruction has been performed, the ICD-10 code N65.1 is not appropriate, as that code specifically applies to disproportion of a reconstructed breast.

For cases of breast asymmetry following lumpectomy without reconstruction, the most accurate code is N64.89, which includes other specified breast disorders and is appropriate for asymmetry unrelated to reconstruction.

Using the correct diagnosis code supports accurate documentation, billing compliance, and quality reporting. Misapplying codes such as N65.1 may result in claim denials or inaccurate clinical data.

Thank you for reaching out to KZA with your inquiry.

*This response is based on the best information available as of 03/05/26.