V45.71 for patial mastectomy

pareli

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I am auditing oncology charts and one of the coders insists on using V45.71 when the patient has had a partial mastectomy. I believe it is not appropriate since she still has part of her breast still. Any thoughts?
 

cblack712

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According to the Coders Desk Reference V45.71 is only intended for use when the condition itself is reported at the diagnosis or problem. Usually a patient with a partial mastectomy will have another reason for additional testing - i/e pain at site, new mass / calcs. If there is no reason I have always been told to code for high risk screening or the reason for the parital mastectomy, especially if the test is a follow-up for the mastectomy.
 
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