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Wiki Current vs Malignancy

E

eccm7862

Networker
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25
Location
Syracuse, IN
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Patient with hx of bilateral mastectomy and bilateral TRAM flap breast reconstruction in 2019. Provider notes on OP report "History of Breast Cancer" and OV note states that the patient would like improvement of symmetry of bilateral breast. Patient is not undergoing any treatments and in survivorship program. Would you bill with DX Z85.3 or with C50.411 based on Coding Guidelines Section I.C.2.m since it is an additional surgery for a malignancy?
 
This is not an additional surgery for malignancy, since there is no current treatment, no prophylactic treatment, nor any indication of current cancer.
 
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