HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit.

She has undergone since her last visit an abdominopelvic CT, which was normal. She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux. She has a minimal delayed emptying secondary tertiary contractions. PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates. Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia. She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.

PHYSICAL EXAMINATION: BP: 117/78. RR: 18. P: 93.

WT: 186 lbs. RAS: 100%.
HEENT: Mucous membranes are moist. No cervical or supraclavicular lymphadenopathy.
LUNGS: Clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm without murmurs.
EXTREMITIES: No cyanosis, clubbing or edema.
NEURO: Alert and oriented x3. Cranial nerves II through XII intact.

ASSESSMENT: Patient here for surveillance with history of lung cancer with no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.

PLAN: She is to return to clinic in six months with a chest CT. She will be called with the results. She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. for esophageal spasm.

ICD-10-CM Code(s):   – Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm

– Z90.2 Acquired absence of lung (part of)

– Z85.118 Personal history of other malignant neoplasm of bronchus and lung

Rationale:  This example states the patient presented for a surveillance visit with a history of lung cancer. Under code Z08 there are two instructional notes that indicate other codes and their sequencing. The first one states to use an additional code to identify any acquired absence of organs. This patient had a left upper lobectomy, so the second listed code is the absence of the lung. The next instructional note states to use an additional code to identify the personal history of malignant neoplasm, in this case the lung. According to the ICD-10-CM guidelines (I.C.2d), when a primary malignancy has been previously excised or eradicated form its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.


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