Wiki Breast cancer listed under the PMH

[ils62390]

I am coding an outpatient office note. The physician states Breast CA under the PMH, there is no surgical history, but he lists the Breast CA under the Assessment. Should this be coded as a current CA or a history of CA?

 

[ohn0disaster]

Is there any indication of any treatment or management? Or is it just listed as "Breast Cancer" with no other references to the DX in the entire note?

 

[ils62390]

There was no mention of the Breast Cancer anywhere other than it was mentioned as "history of" under the PMH section of the note. It looks to me like it is an electronic record that just puts all dx codes that this patient may have had.

 

[terribrown]

If there is no mention of meds or ongoing treatment, you must code "personal history of neoplasm of the breast" V10.3

 

[NaliniAAPC]

Hi,

Yes , you can code history of neoplasm of the breast- V10.3, there is no other documentation for ongoing treatment.

Regards,
Nalini CPC