Granulomatous mastitis, bilateral breast

This code signifies a chronic inflammatory condition of both breasts characterized by the formation of granulomas. It is a non-infectious process, often presenting with palpable masses, pain, and skin changes. The inflammation is typically sterile and can mimic other breast pathologies.

Apply this code when documentation clearly indicates a diagnosis of granulomatous mastitis affecting both breasts. This diagnosis is usually confirmed by biopsy showing non-caseating granulomas. Use for patients presenting with bilateral breast lumps, tenderness, or inflammatory signs where other causes like infection or malignancy have been ruled out.

• Ensure the documentation explicitly states "bilateral" to support this specific code.
• Differentiate from other forms of mastitis (e.g., infectious, periductal) which have distinct codes.
• Code any associated symptoms or complications, such as abscess formation or fistula, in addition to this primary diagnosis.