I'm confused about principal diagnosis for this encounter in which pt comes for refill of medication, s/p lumpectomy. I've read the admonitions not to give the patient what she no longer has, but if she's still under treatment for it...?? Provider's brief note below and dx code he chose.
Subjective: She underwent lumpectomy for left breast intraductal papilloma. Here for refill of medicine.
Exam (cursory exam of heart, lungs, abdomen)
A/P: Breast lump, N63. Will refill APAP (acetaminophen).
-- Pt had left breast mass; biopsy; intraductal papilloma with focal atypia
Do I code D24.2, benign neoplasm of left breast, though it was removed? (Also, as I understand it, papillomas are benign, and the "atypia" here doesn't mean cancer, so I wouldn't code it as cancer, right?)
Any help is much appreciated. Thank you!
Subjective: She underwent lumpectomy for left breast intraductal papilloma. Here for refill of medicine.
Exam (cursory exam of heart, lungs, abdomen)
A/P: Breast lump, N63. Will refill APAP (acetaminophen).
-- Pt had left breast mass; biopsy; intraductal papilloma with focal atypia
Do I code D24.2, benign neoplasm of left breast, though it was removed? (Also, as I understand it, papillomas are benign, and the "atypia" here doesn't mean cancer, so I wouldn't code it as cancer, right?)
Any help is much appreciated. Thank you!
