Wiki Breast cancer treatment after mastectomy

[LuckyLily]

Patient had a left upper inner breast cancer (C50.212) and decided to have a bilateral mastectomy. Patient is now on adjuvant hormonal therapy (Tamoxifen), for 5 years. Is the specific location of the breast cancer still coded (left upper inner C50.212) or should it be C50.919-malignant neoplasm of unspecified site of unspecified female breast, since the cancer is no longer in the left upper inner breast?

The best coding clinic I can find is 2009, 3Q - Herceptin therapy for breast cancer. The question submitted doesn't give a specific location of the breast cancer so an unspecified code was given in response.

Thanks for the help

 

[csperoni]

I would always recommend the more specific code. Having removed the cancer does not change where it was located. Since you are actively treating the breast cancer, using the active C code is appropriate vs history of Z code.

 

[LuckyLily]

Follow up question;
Same scenario as above, patient had mastectomy and on Tamoxifen, but now the TNM stage is given, such as T4N2M0. Pathology confirms the lymph mets. Would you code the N2 (lymph mets) as well? Provider does not specifically state lymph mets, just used the TNM stage in documentation.

 

[csperoni]

If the provider is documenting the N2, I believe it would be appropriate to code secondary malignancy of lymph nodes. I would default to C77.9 since the provider does not specify which lymph nodes.
I also think it's not ideal documentation on behalf of the provider, and it would be very easy for a non-oncology specialized coder to miss that. If it is a provider I work with on a regular basis, I might include this example in education.