Wiki 1 year follow up visit after breast reconstruction

apoland

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I have a patient who is being seen for their 1 year post reconstruction for breast cancer follow up. Z08 and Z85.3 post say they are not acceptible primary diagnoses. What should I be using?? Patient has no issues.

"On examination she’s alert and cooperative in no acute distress. She’s very pleased with her reconstruction. On examination of her reconstructed breast mound she has an excellent result without concerns. Scars are fading quite nicely. At this point there is no need to consider change or intervention. I’ll see her back on an annual basis at her request."

Thanks!
 
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