Introduction

Benign Breast Disease refers to noncancerous conditions such as breast cysts, fibrocystic changes, fibroadenomas, papillomas, duct ectasia, fat necrosis, and mastitis. Common symptoms include breast lumps, pain, swelling, nipple discharge, and abnormal imaging findings.

Most benign breast conditions are not cancer, but some require imaging, biopsy, treatment, or follow-up. For healthcare providers and medical billing teams, accurate documentation is equally important because the ICD-10-CM and CPT codes must match the diagnosis and services documented for the date of service.

This guide covers the most common benign breast disease types, symptoms, diagnosis, treatment, ICD-10-CM codes, CPT codes, and billing considerations.

What Is Benign Breast Disease?

A benign breast condition is a breast disorder that is not breast cancer. The term encompasses structural, cystic, proliferative, inflammatory, traumatic, and other nonmalignant disorders.

Common examples include:

• Fibrocystic breast changes
• Simple breast cysts
• Fibroadenoma
• Intraductal papilloma
• Mammary duct ectasia
• Fat necrosis
• Lipoma
• Sclerosing adenosis
• Radial scar/complex sclerosing lesion
• Benign breast calcifications
• Mastitis and breast abscess
• Certain benign proliferative lesions
• Atypical hyperplasia, which is noncancerous but clinically important because it can increase future breast cancer risk

The American College of Obstetricians and Gynecologists notes that benign breast conditions can involve pain, masses, infection, nipple discharge, or skin changes. It also distinguishes nonproliferative lesions from proliferative lesions and atypical hyperplasia because their implications for future breast cancer risk are different.

From a revenue-cycle perspective, “benign breast disease” is not one universal ICD-10-CM diagnosis code. The correct code depends on the documented condition, whether the diagnosis has been established, the breast involved, and—in applicable categories—the exact location of the lesion.

Types of Benign Breast Disease

1. Fibrocystic Breast Changes

Fibrocystic changes are among the most common benign breast conditions. Patients may report generalized lumpiness, breast swelling, tenderness, nipple sensitivity, or discomfort that varies with the menstrual cycle.

The National Cancer Institute describes fibrocystic breast changes as benign changes that can include irregular lumps, cysts, swelling, discomfort, sensitive nipples, and itching. Symptoms may fluctuate with hormonal changes and often decrease after menopause.

For coding, the specific documented diagnosis may fall under the N60.- benign mammary dysplasia family rather than a generic breast lump code.

2. Breast Cysts

A breast cyst is a fluid-filled sac within breast tissue. Cysts may be microscopic or large enough to palpate. They can become more noticeable or painful around the menstrual cycle.

Ultrasound is particularly useful for distinguishing a fluid-filled cyst from a solid mass. Large or symptomatic cysts may be aspirated, which can both establish the nature of the lesion and relieve symptoms.

Common ICD-10-CM codes include:

• N60.01 — Solitary cyst of right breast
• N60.02 — Solitary cyst of left breast
• N60.09 — Solitary cyst of unspecified breast

3. Fibroadenoma

Fibroadenoma is a common benign breast tumor, particularly among younger patients. It often presents as a firm, smooth, mobile, well-defined mass. Many fibroadenomas are asymptomatic.

The diagnosis may be made through imaging, clinical examination, core biopsy, or excision depending on the patient’s age, imaging appearance, growth pattern, and clinical circumstances. Many fibroadenomas can be observed, while rapidly growing, symptomatic, atypical, or diagnostically uncertain lesions may require removal.

When pathology establishes a benign neoplasm of the breast, the ICD-10-CM category generally used is D24.-:

• D24.1 — Benign neoplasm of right breast
• D24.2 — Benign neoplasm of left breast
• D24.9 — Benign neoplasm of unspecified breast

Do not automatically code every palpable fibroadenoma as D24.- before the diagnosis is established. The appropriate diagnosis for an initial diagnostic encounter may instead be the documented mass or imaging abnormality.

4. Intraductal Papilloma

An intraductal papilloma is a benign epithelial growth arising within a breast duct. A solitary papilloma near the nipple may cause spontaneous nipple discharge, including clear or bloody discharge, and occasionally a palpable mass.

Multiple papillomas and papillomas with atypia can have different clinical implications. NCI notes that multiple papillomas are associated with some increase in future breast cancer risk.

The exact ICD-10-CM selection should follow the provider’s documented final diagnosis and the classification of the lesion. A confirmed benign neoplasm may be represented with D24.-, while an unresolved finding may require symptom or abnormal-imaging coding.

5. Mammary Duct Ectasia

Mammary duct ectasia occurs when a milk duct becomes widened and may become associated with inflammation or discharge. It is benign but can clinically resemble other causes of nipple discharge.

The ICD-10-CM family includes:

• N60.41 — Mammary duct ectasia of right breast
• N60.42 — Mammary duct ectasia of left breast
• N60.49 — Mammary duct ectasia of unspecified breast

6. Fat Necrosis

Fat necrosis can produce a firm breast lump following trauma, surgery, radiation, or other injury to breast tissue. It can mimic malignancy on physical examination or imaging.

The relevant ICD-10-CM category is:

• N64.1 — Fat necrosis of breast

NCI describes fat necrosis as typically producing a round, firm, often painless lump and notes that it may occur after breast injury, surgery, or radiation.

7. Lipoma

A breast lipoma is a benign tumor composed primarily of fatty tissue. It is commonly soft, mobile, and painless.

The coding choice depends on how the lesion is documented and classified. A benign neoplasm of the breast may fall under D24.-, while a lesion documented as a lipoma of the skin or another anatomical structure may require a different code. Coders should not infer the anatomic origin solely from the word “lipoma.”

8. Sclerosing Adenosis and Radial Scar

Sclerosing adenosis involves increased fibrous tissue and glandular structures within breast lobules. Radial scar, also called a complex sclerosing lesion, can have an imaging appearance that warrants biopsy even though the lesion itself is benign.

NCI identifies sclerosing adenosis and radial scars among benign conditions that may be associated with increased breast cancer risk.

These are important examples of why benign does not necessarily mean clinically insignificant.

9. Mastitis and Breast Abscess

Mastitis involves inflammation of breast tissue and may occur during breastfeeding or outside the postpartum period. Symptoms can include pain, warmth, swelling, redness, fever, and systemic symptoms.

A breast abscess is a localized collection of infected material and may require drainage.

Relevant ICD-10-CM codes include:

• N61.0 — Mastitis without abscess
• N61.1 — Abscess of the breast and nipple
• N61.20 — Granulomatous mastitis, unspecified breast
• N61.21 — Granulomatous mastitis, right breast
• N61.22 — Granulomatous mastitis, left breast
• N61.23 — Granulomatous mastitis, bilateral breast

Symptoms of Benign Breast Disease

Benign breast disease can be asymptomatic or present with findings that overlap with breast cancer.

Common symptoms and signs include:

• Palpable breast lump
• Generalized breast lumpiness
• Breast pain or tenderness
• Cyclic breast pain
• Breast swelling
• Nipple discharge
• Nipple sensitivity
• Nipple retraction
• Skin changes
• Localized inflammation
• Redness or warmth
• Post-traumatic breast lump
• Imaging-detected mass or calcification

A key clinical and coding principle is that symptom presentation does not establish the final pathology.

For example, a patient with a new breast lump should not have a benign neoplasm code simply because the clinician suspects a fibroadenoma. Until the diagnosis is established, the documented lump or abnormal imaging finding may be the appropriate diagnosis.

ACOG also distinguishes cyclic breast pain from noncyclic breast pain. Hormonal changes can contribute to cyclic pain, whereas noncyclic pain can have causes such as injury, infection, medications, or breast size.

Causes and Risk Factors

There is no single cause of benign breast disease. Different disorders have different mechanisms.

Potential contributing factors include:

• Normal hormonal fluctuations
• Menstrual-cycle changes
• Pregnancy
• Menopausal hormone therapy
• Hormonal contraception
• Breast trauma
• Previous breast surgery
• Radiation exposure to breast tissue
• Duct obstruction or dilation
• Infection
• Age
• Individual breast anatomy
• Proliferative tissue changes

For example, breast cysts are believed to be influenced by hormonal changes, while fibroadenomas may respond to hormonal influences and can change during pregnancy or menopause.

A patient’s risk history also affects diagnostic decision-making. A new breast mass in a young, low-risk patient may be approached differently from a new mass in a patient with a previous breast cancer diagnosis or significant hereditary risk.

How Is Benign Breast Disease Diagnosed?

Diagnosis typically combines:

1. Clinical history
2. Breast examination
3. Diagnostic imaging
4. Tissue sampling when indicated
5. Pathology correlation
6. Clinical and imaging follow-up

Clinical Evaluation

The clinician should document:

• Location of the lesion
• Breast and side
• Approximate size
• Duration
• Whether the lesion is new or previously known
• Mobility and consistency
• Pain or tenderness
• Skin changes
• Nipple findings
• Nipple discharge
• Relevant trauma or surgery
• Pregnancy/lactation status when clinically relevant
• Prior imaging
• Family and personal breast history when relevant

This information supports both medical decision-making and accurate diagnosis coding.

Mammography

Diagnostic mammography is commonly used when a breast symptom or abnormality requires evaluation. Current 2026 CPT/HCPCS reporting includes:

• 77065 — Diagnostic mammography, unilateral
• 77066 — Diagnostic mammography, bilateral
• 77061 — Unilateral breast tomosynthesis
• 77062 — Bilateral breast tomosynthesis
• 77063 — Screening bilateral breast tomosynthesis

CMS’s current 2026 materials identify 77065 and 77066 as diagnostic mammography codes and distinguish diagnostic imaging from screening mammography.

Breast Ultrasound

Common breast ultrasound codes include:

• 76641 — Complete ultrasound examination of a breast
• 76642 — Limited ultrasound examination of a breast

CMS data continues to identify 76641 and 76642 as active breast ultrasound services.

Ultrasound is particularly useful for determining whether a palpable or imaging-detected lesion is cystic or solid.

Breast MRI

Common breast MRI CPT codes include:

• 77046 — Breast MRI without contrast, unilateral
• 77047 — Breast MRI without contrast, bilateral
• 77048 — Breast MRI with and without contrast, unilateral
• 77049 — Breast MRI with and without contrast, bilateral

CMS lists these breast MRI services in its Medicare coding materials.

MRI is not automatically appropriate for every benign breast complaint. Its use should be supported by the clinical scenario, imaging findings, patient risk, and applicable coverage criteria.

Understanding BI-RADS and Benign Breast Findings

The American College of Radiology BI-RADS system standardizes breast imaging terminology, assessment, and management.

In general:

The ACR emphasizes that BI-RADS assessment categories and management recommendations should be clearly reported and that category 3 is reserved for appropriately evaluated findings with a very low likelihood of malignancy.

Coding point: BI-RADS 2 does not itself replace the underlying clinical diagnosis. If the encounter is for a documented benign cyst, fibroadenoma, breast pain, or other condition, the diagnosis code should reflect the condition documented by the treating provider. If the encounter is specifically for an abnormal imaging finding before a definitive diagnosis has been established, an appropriate R92.- abnormal-imaging code may be relevant.

Benign Breast Disease ICD-10-CM Codes

For U.S. coding, the most useful ICD-10-CM codes depend on whether the provider has documented a confirmed benign disease, a symptom, an abnormal imaging finding, or a neoplasm.

The following table covers commonly encountered codes for benign breast workups. It is not a substitute for the complete FY 2026 ICD-10-CM Tabular List and Alphabetic Index.

Common ICD-10-CM Diagnosis Codes

CMS’s FY 2026 materials specifically list the laterality-specific N60.- and N63.- codes and the N64.- breast signs and symptoms above.

Coding the Breast Lump Before Final Diagnosis

One of the most common billing mistakes is coding a suspected benign tumor as though pathology has already confirmed it.

Example:

A patient presents with a new right breast mass. Ultrasound identifies a solid lesion and the radiologist recommends biopsy. The physician documents “right breast mass, rule out fibroadenoma.”

For the diagnostic encounter, a laterality- and location-specific N63.- code may be more appropriate than D24.1, because the benign neoplasm has not yet been established.

After pathology confirms a benign breast neoplasm, the confirmed diagnosis can be coded according to the final pathology and provider documentation.

CMS specifically emphasizes the importance of capturing the side of the breast involved because incomplete laterality can affect claims and medical-necessity review.

CPT Codes Commonly Used in Benign Breast Disease Workups

There is no single CPT code for “benign breast disease.” CPT reporting depends on the service performed.

Evaluation and Management

Depending on the setting and circumstances, office/outpatient E/M services may include:

• 99202–99205 — New patient office/outpatient E/M
• 99211–99215 — Established patient office/outpatient E/M

The actual level should be selected using the current CPT E/M rules based on medical decision-making or total time, as applicable. Do not select an E/M level merely because a breast diagnosis appears complex.

Diagnostic Imaging

Common codes include:

• 76641 — Complete breast ultrasound
• 76642 — Limited breast ultrasound
• 77061 — Unilateral diagnostic breast tomosynthesis
• 77062 — Bilateral diagnostic breast tomosynthesis
• 77065 — Diagnostic mammography, unilateral
• 77066 — Diagnostic mammography, bilateral
• 77046–77049 — Breast MRI services, according to contrast and laterality
• 77063 — Screening bilateral tomosynthesis
• 77067 — Screening mammography, bilateral

The screening versus diagnostic distinction matters. A symptomatic patient being evaluated for a new mass is not automatically a screening encounter simply because the patient is due for screening.

Breast Cyst Aspiration

Common procedure codes include:

• 19000 — Puncture aspiration of cyst of breast
• 19001 — Each additional cyst

CMS materials identify 19000 and 19001 as breast cyst aspiration services.

Documentation should establish what cyst was treated, the side, location when relevant, clinical indication, and procedure performed.

Breast Biopsy

Common image-guided biopsy codes include:

• 19081 — First breast lesion, percutaneous biopsy with stereotactic guidance
• 19082 — Each additional lesion, stereotactic guidance
• 19083 — First breast lesion, ultrasound guidance
• 19084 — Each additional lesion, ultrasound guidance
• 19085 — First breast lesion, MRI guidance
• 19086 — Each additional lesion, MRI guidance

CMS specifically recognizes 19081–19086 for image-guided breast biopsy services and states that additional lesions must be clearly documented.

Practical Billing Example

Suppose a patient has two right-breast lesions. The first lesion is biopsied under ultrasound guidance and the second lesion is also biopsied under ultrasound guidance.

The procedural coding structure generally involves:

• 19083 — first lesion
• 19084 — additional lesion

The operative/procedure note should identify the lesions separately and document the guidance method. Do not report the additional-lesion code merely because two samples were taken from the same lesion; the coding concept is based on additional lesion(s), not simply additional specimen cores.

Surgical Excision

Depending on the procedure performed, relevant CPT families can include:

• 19120 — Excision/removal of breast lesion
• 19125 — Excision of breast lesion identified by preoperative placement of a localization device
• 19126 — Each additional breast lesion identified by localization
• 19101 — Incisional biopsy when applicable
• 19110/related nipple or duct procedures when clinically appropriate

CMS materials identify 19120, 19125, and 19126 among breast procedures.

The exact CPT selection must follow the current CPT descriptor and operative documentation. A surgeon should not select a localization-specific excision code merely because imaging was performed before surgery; the record must support the localization method and procedure.

Breast Localization

When localization is required before excision, CPT codes may include:

• 19281–19282 — Mammographic guidance/localization
• 19283–19284 — Stereotactic localization
• 19285–19286 — Ultrasound-guided localization
• 19287–19288 — MRI-guided localization

CMS documentation identifies these breast localization code families and distinguishes first and additional lesions.

Pathology

Pathology may involve CPT codes such as:

• 88305 — Surgical pathology examination, commonly applicable to many breast tissue specimens
• Additional pathology or immunohistochemistry codes when supported by the specimen and diagnostic work

Pathology coding must be based on the actual specimen and services performed. Coders should not assume that every benign breast biopsy automatically generates the same pathology code set.

Benign Breast Disease Billing: What Coders and Billers Should Check

A clean claim begins with clinical documentation that answers the questions the payer is likely to ask.

1. Is the Diagnosis Confirmed?

Distinguish among:

• Symptom
• Physical finding
• Imaging finding
• Suspected diagnosis
• Biopsy diagnosis
• Final pathology diagnosis

A suspected fibroadenoma is not necessarily coded the same way as a pathology-confirmed fibroadenoma.

2. Is Laterality Documented?

Whenever the ICD-10-CM category provides right, left, or unspecified options, use the most specific documented choice.

For example:

• Right breast → use the right-sided code
• Left breast → use the left-sided code
• Bilateral disease → use bilateral coding when the code set provides it
• Do not use unspecified laterality when the clinical record clearly identifies the side

3. Is the Quadrant Documented?

For N63.- breast lump codes, location can matter. Documentation may identify:

• Upper outer quadrant
• Upper inner quadrant
• Lower outer quadrant
• Lower inner quadrant
• Overlapping quadrants
• Axillary tail
• Subareolar region
• Unspecified quadrant

The FY 2026 ICD-10-CM structure includes these distinctions.

4. Does the Imaging Match the Diagnosis?

For diagnostic breast imaging, the claim should make clinical sense.

For example:

Assessment: New palpable left breast mass at 2 o’clock.
Plan: Diagnostic bilateral mammography with targeted left breast ultrasound.

This documentation provides a logical connection among the symptom, laterality, imaging, and medical necessity.

5. Is the Biopsy Procedure Note Complete?

For image-guided breast biopsy, the documentation should generally establish:

• Indication
• Breast and lesion location
• Number of lesions
• Imaging modality used for guidance
• Biopsy technique
• Specimen acquisition
• Localization clip/device when placed
• Specimen imaging when performed
• Complications
• Post-procedure instructions
• Pathology submission

CMS specifically states that additional lesions requiring biopsy and the breast involved must be clearly documented.

6. Watch for Bundling and Duplicate Imaging

Do not automatically add separate imaging codes simply because imaging occurred during a procedure.

CMS NCCI guidance has historically emphasized that the imaging guidance included in certain breast biopsy procedures should not be separately reported when it is integral to the biopsy service. Current NCCI edits and the current CPT code descriptors should be checked for the date of service.

Diagnosis-to-Procedure Coding Examples

Example 1: New Palpable Breast Lump

Clinical scenario:
A patient presents with a new palpable right breast lump. No definitive diagnosis has been established.

Possible diagnosis coding:
A specific N63.1x code based on documented quadrant may be appropriate.

Potential services:
Diagnostic mammography, ultrasound, and possibly E/M.

Coding principle:
Do not assign a benign neoplasm code simply because the clinician believes the lesion is probably a fibroadenoma.

Example 2: Confirmed Simple Breast Cyst

Clinical scenario:
Ultrasound identifies a symptomatic simple cyst in the left breast. The clinician performs aspiration.

Possible diagnosis:
N60.02 — Solitary cyst of left breast

Possible CPT:
19000 for aspiration of the breast cyst, subject to the exact procedure and current CPT descriptor.

The diagnosis and procedure should correspond to the cyst actually treated.

Example 3: Ultrasound-Guided Biopsy of a Right Breast Mass

Clinical scenario:
A right breast mass is identified on diagnostic imaging. Ultrasound-guided core biopsy is performed.

Before pathology:
A documented right breast mass or abnormal imaging finding may support the diagnosis code.

Procedure:
19083 for the first lesion when the service meets the CPT descriptor for ultrasound-guided percutaneous breast biopsy.

CMS identifies 19083 as the first-lesion ultrasound-guided breast biopsy code.

Example 4: Pathology-Confirmed Benign Breast Neoplasm

Clinical scenario:
A previously biopsied right breast lesion is confirmed as a benign neoplasm and the patient returns for surgical management.

Possible diagnosis:
D24.1 — Benign neoplasm of right breast

The final diagnosis should be supported by the pathology and provider documentation.

Medical Necessity and Payer Considerations

A CPT code establishes what service was performed. An ICD-10-CM code establishes why the patient received the service. Neither code independently guarantees payment.

Coverage may depend on:

• Payer
• Patient’s benefit plan
• Medicare status
• Medical necessity
• Prior authorization
• Site of service
• Provider participation
• Frequency limitations
• Screening versus diagnostic indication
• Applicable LCD/NCD
• Commercial payer medical policy
• Documentation
• Modifier requirements
• National and local coding edits

CMS maintains annual Physician Fee Schedule files. For 2026, CMS has published January, April, and July PFS releases, and payment amounts can vary based on locality and other Medicare payment factors.

Therefore, a practice should avoid publishing a single universal “Medicare reimbursement amount” for a breast procedure without identifying the applicable year, locality, place of service, and payment file.

Common Benign Breast Disease Coding Errors

Error 1: Using D24.- for Every Benign-Looking Mass

A mass that appears benign on imaging is not automatically a confirmed benign neoplasm.

Better approach: Code the documented finding or established diagnosis for the encounter.

Error 2: Ignoring Laterality

Using an unspecified breast code when the physician documents right or left breast can reduce specificity and may create medical-necessity problems.

Error 3: Confusing Screening and Diagnostic Mammography

A patient presenting because of a palpable mass, nipple discharge, or abnormal prior imaging generally requires diagnostic evaluation rather than simply reporting a screening indication.

Error 4: Coding the Pathology Result for the Earlier Encounter

The final pathology result may not have been known when the original imaging or biopsy occurred.

Code according to the documentation and coding rules applicable to the specific encounter.

Error 5: Reporting an Additional-Lesion Code for Additional Samples

Multiple tissue cores from one lesion are not automatically multiple lesions.

Error 6: Separately Reporting Integral Imaging

Image-guided procedures may include the imaging guidance needed to perform the procedure. Review CPT instructions and current NCCI edits before separately reporting imaging services.

Error 7: Using Unspecified Codes When Better Documentation Exists

A breast lump documented as “left breast, upper outer quadrant” should not routinely be reduced to “unspecified lump in unspecified breast.”

Documentation Checklist for Providers

For breast-related encounters, a strong note should establish the clinical story and support the services billed.

History

• New or established finding
• Duration
• Change in size
• Pain or tenderness
• Cyclic symptoms
• Nipple discharge
• Trauma
• Prior surgery
• Prior imaging/biopsy
• Relevant personal history

Examination

• Breast
• Side
• Lesion location
• Size
• Consistency
• Mobility
• Skin findings
• Nipple findings
• Regional lymph nodes when clinically relevant

Assessment

• Confirmed diagnosis, if known
• Differential diagnosis when appropriate
• Relevant imaging interpretation
• BI-RADS assessment when applicable

Plan

• Observation
• Repeat imaging
• Diagnostic mammography
• Ultrasound
• MRI
• Aspiration
• Core biopsy
• Surgical consultation
• Excision
• Follow-up interval

Procedure documentation

• Exact lesion treated
• Side
• Location
• Guidance method
• Number of lesions
• Device/clip placement
• Specimen handling
• Complications
• Pathology submission

This level of documentation helps clinicians communicate clearly and gives coders enough information to select the most specific diagnosis and procedure codes supported by the record.

Benign Breast Disease: Quick Coding Reference

This table is a practical orientation tool, not an exhaustive coding matrix. The correct code depends on the exact documentation and the code set effective on the date of service.

What Is the Difference Between a Benign Breast Lump and Breast Cancer?

A palpable lump cannot reliably be classified as benign based only on how it feels.

Benign lesions such as cysts and fibroadenomas can produce palpable masses, while malignant lesions can also present as a lump. Conversely, some benign or malignant abnormalities are detected only on imaging.

A new lump, persistent change, nipple retraction, concerning nipple discharge, skin dimpling, or other breast change should be clinically evaluated. Mayo Clinic notes that changes such as persistent or changing lumps, skin changes, repeated nipple discharge, nipple inversion, or an enlarging axillary lump warrant medical assessment.

The coding implication is important: do not let the appearance of a lesion determine the diagnosis code when the medical record has not established the diagnosis.

Frequently Asked Questions About Benign Breast Disease

Is benign breast disease cancer?

No. Benign breast disease refers to noncancerous breast conditions. However, certain benign proliferative lesions and atypical lesions can increase future breast cancer risk.

What is the ICD-10-CM code for benign breast disease?

There is no single ICD-10-CM code for every case of Benign Breast Disease. Depending on the diagnosis, commonly used categories include D24.- for benign neoplasm of breast, N60.- for benign mammary dysplasia and related conditions, and N64.- for other breast disorders and symptoms.

What is the ICD-10 code for a benign breast tumor?

When the provider documents a benign neoplasm of breast, the common category is D24.-:

• D24.1 — right breast
• D24.2 — left breast
• D24.9 — unspecified breast

The final selection must follow the current ICD-10-CM code set and documentation.

What is the ICD-10 code for a breast lump?

The N63.- family is used for unspecified breast lumps, with codes providing increasing specificity for side and anatomical location. FY 2026 includes right- and left-breast quadrant, axillary-tail, and subareolar distinctions.

What CPT code is used for a breast biopsy?

Common image-guided breast biopsy codes include 19081–19086. The specific code depends primarily on the imaging guidance method and whether the lesion is the first or an additional lesion.

What CPT code is used for a breast cyst aspiration?

19000 is commonly used for breast cyst aspiration, with 19001 for an additional cyst when the CPT descriptor and documentation support it.

Does a BI-RADS 2 result mean the patient has a benign breast disease diagnosis?

BI-RADS 2 indicates a benign imaging assessment, but the diagnosis code should still reflect the condition documented for the encounter. BI-RADS is an imaging assessment system, not a universal ICD-10-CM diagnosis code.

Should a suspected fibroadenoma be coded as D24.1 or D24.2?

Not necessarily. If the lesion has not been established as a benign neoplasm, a documented breast mass or imaging finding may be more appropriate. Once pathology or the provider establishes the definitive diagnosis, the confirmed condition can be coded accordingly.

Does benign breast disease require treatment?

Not always. Simple cysts and uncomplicated fibroadenomas may require observation rather than treatment. Symptomatic cysts may be aspirated, infections may require antibiotics or drainage, and selected lesions may require excision or surveillance. Treatment depends on the exact condition and patient circumstances.

Does benign breast disease increase breast cancer risk?

Some benign conditions do not increase risk, while others—including certain proliferative lesions and atypical hyperplasia—can increase future risk. The specific pathology matters.

2026 Coding and Compliance Note

For services performed in 2026, coding teams should verify:

1. The FY 2026 ICD-10-CM version applicable to the encounter date.
2. The 2026 CPT code set and current CPT descriptors.
3. Current CMS Physician Fee Schedule information for Medicare services.
4. Current NCCI edits.
5. The applicable Medicare Administrative Contractor policy.
6. Commercial payer medical-necessity and authorization rules.
7. Screening versus diagnostic benefit requirements.
8. Correct laterality and anatomical site.
9. Whether the diagnosis was established at the time of service.
10. Whether imaging guidance is already included in the procedure code.

CMS states that the FY 2026 ICD-10-CM files cover encounters in the applicable FY 2026 periods and provides separate updated files for the April 1, 2026 through September 30, 2026 period. As of August 21, 2026, claims for current encounters should therefore be checked against the applicable FY 2026 release rather than an older ICD-10-CM version.

CMS also publishes 2026 PFS updates during the year, so practices should use the applicable payment release and locality rather than relying on an outdated fee schedule.

Final Takeaway

Benign Breast Disease includes many conditions with different diagnostic, treatment, and coding requirements. Accurate documentation of the diagnosis, breast laterality, lesion location, and services performed helps providers and billing teams select the correct ICD-10-CM and CPT codes.

Most importantly, code only the diagnosis established for the date of service. Always verify current ICD-10-CM, CPT, NCCI, Medicare, and payer-specific requirements to support accurate and compliant billing.