Z90.13 Acquired absence of bilateral breasts and nipples

Name of the Condition

• Acquired Absence of Bilateral Breasts and Nipples

Summary

Acquired absence of bilateral breasts and nipples refers to the loss or removal of both breasts and nipples, typically resulting from surgical intervention such as bilateral mastectomy. This condition is documented using the ICD-10-CM code Z90.13.

Causes

The absence of both breasts and nipples is most commonly due to surgical removal, often for the treatment or prevention of breast cancer. Other causes may include severe trauma, infection, or complications from medical conditions requiring resection.

Risk Factors

• Personal or family history of breast cancer.
• Genetic mutations (e.g., BRCA1 or BRCA2).
• Previous radiation exposure to the chest.
• Prophylactic mastectomy for high-risk individuals.

Symptoms

• Physical absence of both breasts and nipples.
• Scarring or changes in skin texture at the surgical sites.
• Possible numbness or sensitivity in the chest area.

Diagnosis

Diagnosis is typically based on medical history and physical examination. Imaging studies (e.g., mammograms, MRIs) may document pre- and post-surgical changes, confirming the absence of both breasts and nipples.

Treatment Options

• Breast reconstruction surgery to restore the breast mounds and nipples.
• Use of external breast prostheses or forms.
• Physical therapy to improve shoulder and chest mobility.

Prognosis and Follow-Up

Prognosis depends on the underlying reason for the absence and any subsequent treatments. Regular follow-up care, including monitoring for recurrence or complications, is important for long-term health management.

Complications

• Surgical site infections or healing issues.
• Psychological or emotional impacts related to body image.
• Potential functional limitations in the chest or shoulder area.

Lifestyle & Prevention

• Engage in regular health screenings as recommended by a healthcare provider.
• Maintain a balanced diet and exercise routine to support overall well-being.
• Seek support from mental health professionals if needed to address emotional concerns.

When to Seek Professional Help

Consult a healthcare provider if experiencing new or worsening symptoms, such as pain, swelling, or changes in the surgical area, or if emotional distress impacts daily life.

Tips for Medical Coders

When documenting Z90.13, ensure the medical record clearly indicates the acquired absence of both breasts and nipples, including the reason (e.g., surgical removal) and any associated conditions. Verify that the code aligns with the clinical documentation to support accurate coding and billing.