Cases , Coding

Mark Gittleman, MD/

Dr. Gittleman's Coding Corner: Current vs Personal History of Breast Cancer?

Question:  In my practice, I follow my breast cancer patients for many years. Which ICD-10 codes should I use, the current breast cancer  codes or the personal history of breast cancer codes?

Answer:

When a primary invasive malignancy has been diagnosed, or excised, but further treatment, such as additional surgery for the malignancy, radiation therapy, or systemic therapy is directed to that site, the primary malignancy code should be used until treatment is completed;

C50.XXX. (For DCIS, the appropriate codes are D05.XX.)

When a primary invasive malignancy has been previously excised or eradicated from its site, the pt. is not receiving any follow-up treatment, and there is NED, then use the personal history of breast cancer codes:

Z85.3 - Personal history of breast malignancy, and

Z08 – Encounter for follow up exam after completed treatment of malignant neoplasm

Z90.1 – if pt had  mastectomy (acquired absence of breast).

For DCIS or LCIS:

Z86.000 - personal history of in-situ neoplasm of breast

Z08 – Encounter for follow up exam after completed treatment of malignant neoplasm

 

Additionally, use the ER status codes in any of the above examples.

Z17.0 -Estrogen receptor positive status, or

Z17.1 - Estrogen receptor negative status

 

Example: Pt is 4 years S/P treatment of ER+ IDC with BCT and is receiving anti-estrogen therapy, use C50.XXX and Z17.0.

 

Example: Pt is 2 years S/P treatment of ER- , Her2+ IDC with mastectomy, and completed all systemic therapy, use  Z85.3, Z08, Z90.1 and Z17.1

 

Leave A Comment