611.72 or 174.9

Kimberley

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Order states BREAST CANCER

BILATERAL BREAST MRI WITH CONTRAST 3/31/09

HISTORY: LEFT BREAST CANCER

MULTIPLE SEQUENCES WERE PERFORMED WITHOUT AND WITH IV CONTRAST. THERE IS A ENHANCING MASS I THE MID LATERAL LEFT BREAST, MEASURING 2.1 X 2.7 CM. THERE IS MALIGNANT TYPE ENHANCEMENT CONSISTENT WITH PATIENT'S KNOWN HISTORY OF CANCER. THE MASS IS IMMEDIATELY ADJACENT TO LEFT BREAST IMPLANT AND IS CLOSE TO THE SKIN. NO ADDITIONAL MALIGNANT TYPE ENHANCING LESION NOTED. THERE ARE BILATERAL BREAST IMPLANTS IN PLACE WITH EVIDENCE OF INTRACAPSULAR RUPTURE BILATERALLY. THERE IS NO LYMPHADENOPATHY.

IMPRESSION: ENHANCING NODULE LEFT BREAST CONSISTENT WITH PATIENT'S KNOW HISTORY OF CANCER. NO ADDITIONAL MALIGNANT TYPE ENHANCING LESION NOTED.
 

jtuominen

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Yea, I think I still would until there is a biopsy finding. Especially if the patient's current status is only a history of malignancy. Coupled with the Impression section calling it an "enhancing nodule" and not a malignancy. I guess you could always double check with them before you code anything. Just my thought process. Have a good day!
 

dmaec

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Order states BREAST CANCER

BILATERAL BREAST MRI WITH CONTRAST 3/31/09

HISTORY: LEFT BREAST CANCER

MULTIPLE SEQUENCES WERE PERFORMED WITHOUT AND WITH IV CONTRAST. THERE IS A ENHANCING MASS I THE MID LATERAL LEFT BREAST, MEASURING 2.1 X 2.7 CM. THERE IS MALIGNANT TYPE ENHANCEMENT CONSISTENT WITH PATIENT'S KNOWN HISTORY OF CANCER. THE MASS IS IMMEDIATELY ADJACENT TO LEFT BREAST IMPLANT AND IS CLOSE TO THE SKIN. NO ADDITIONAL MALIGNANT TYPE ENHANCING LESION NOTED. THERE ARE BILATERAL BREAST IMPLANTS IN PLACE WITH EVIDENCE OF INTRACAPSULAR RUPTURE BILATERALLY. THERE IS NO LYMPHADENOPATHY.

IMPRESSION: ENHANCING NODULE LEFT BREAST CONSISTENT WITH PATIENT'S KNOW HISTORY OF CANCER. NO ADDITIONAL MALIGNANT TYPE ENHANCING LESION NOTED.
I'd code the breast cancer... because it clearly states that there IS malignant type enhancement consistent with patients known history of cancer AND the impression also says "enhancing nodule left breast consistent with patients know history of cancer" goes on to say no additional malignant type enhancing lesion noted. BUT there is at least ONE..
 

grahamki

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The order states breast cancer 174.9. The beginning of the reading states pt history of breast ca. I would code it out as history of magliancy of the breast v? Dont know the code off of my head. I would also code out the finding of the nodule in the breast. That is just my thought process. :eek:
 

mad_one80

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I agree....I would code 611.72 and the h/o v10.3...unless you have the path and it confirms the breast cancer came back.
 
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