Wiki History of Breast with ER+ and ER -

[ruthan]

Can anyone shed some light... I know if the patient has current breast cancer and a OV is being completed you add the ER + or ER-, however if the patient is strictly a history of breast cancer do you still add the ER's codes. I am pretty sure no but I don't have access to coding clinic to verify. Can someone please add there thoughts... thanks

 

[thomas7331]

In the current ICD-10, the Z85 personal history of malignant neoplasm category does not include the 'Use additional code to identify estrogen receptor status' instruction that is found in the C50 category for active cancer, so I would interpret that to mean the ER status codes are not required if you are coding a history only. However, this instruction is found under Z79.81 Long term (current) use of agents affecting estrogen receptors and estrogen levels, so you would need to add it if you are coding Z79.81 for this patient. I don't have access to Coding Clinic either at the moment, but I can't imagine that they would give any guidance contradictory to ICD-10 instructions on this.

 

[TThivierge]

Hi Ruthan
Here are some more dx codes may help Z17.0 or Z17.1 if positive or negative estrogen combined with Breast Cancer dx C50 which is then coded first. Look at dx E28.0 of excess of estrogen or dx E28. 1 if lack of estrogen. Anyhow...ensure documentation supports which every you choose.
Well I hope I helped you
Lady T

 

[sls314]

Can anyone shed some light... I know if the patient has current breast cancer and a OV is being completed you add the ER + or ER-, however if the patient is strictly a history of breast cancer do you still add the ER's codes. I am pretty sure no but I don't have access to coding clinic to verify. Can someone please add there thoughts... thanks

Hello! That's correct - when using the Z85.3 personal history of breast cancer code, you do not need to use a Z17.- code with it.