Hypoplasia of breast

This diagnosis code signifies the underdevelopment or incomplete formation of breast tissue. It describes a breast that is abnormally small or has not fully matured, which can affect one or both breasts. This condition is typically present from birth or becomes apparent during puberty.

Apply this code when documentation clearly indicates a diagnosis of breast hypoplasia, excluding congenital absence or issues related to breast reconstruction. This code is appropriate for patients presenting with underdeveloped breasts not due to trauma, surgery, or other acquired conditions. Supporting documentation should include physician notes detailing the small size or incomplete development of the breast(s).

• Differentiate from congenital absence (agenesis) of the breast, which is a complete lack of breast tissue.
• Do not use for hypoplasia specifically noted in relation to a reconstructed breast; a different code exists for that scenario.
• Consider laterality if specified in the documentation (e.g., left, right, bilateral) as more specific codes may be available for certain conditions, though N64.82 is a general code for unspecified laterality.