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H/O of primary malignancy with mets

  1. Lightbulb H/O of primary malignancy with mets
    Medical Coding Books
    Clinical information: Specimen is LIVER. “Poorly differentiated carcinoma consistent with metastatic breast carcinoma. History of breast cancer.”

    Question: Based on the clinical information above. Should I code metastatic liver with breast carcinoma as a current diagnoses (197.7, 174.9), OR metastatic liver with history of breast cancer (197.7, V10.3), OR should I code all 197.7, 174.9, V10.3?

    Thank you

  2. #2
    Columbia, MO
    given what is documented with access to other information then

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    From a clinical perspective, if the liver cancer is a metastasis from the breast, that means the breast still has cancer. I would think to code the breast cancer as a current diagnoses because although it was treated, the cancer came back and had spread to the liver. Therefore, I would code 197.7, 174.9. Any thoughts?

  4. #4
    Columbia, MO
    The actual breast site as the primary location can be without evidence of disease while the cancer cells have invaded other organs in this case the liver. Another way to think of this is the patient now has breast cancer located in the liver but the primary location of the breast now without evidence of disease. so hx of with mets with no other indication that the primary is still being treated is code the primary as hx of.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    That makes more sense when you say it like that and it stays true to the coding guidelines. Thank you so much for your feedback.

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