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case study

  1. Question case study
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    Ellen is a 65 y/o female who presents today with severe headaches and blurred vision. She said these symptoms have been going on for appox 2 weeks. She says tht the pain is 10 out of 10 and that nothing seems to help relieve it. She has a history of breast cancer, which has been in remission for 1 year. A CT scan of the head and neck reveals a tumor in the temporal lobe of the brain. A biopsy was performed and confirmed this to be a metastasis from the breast tumor.

    Question how would this be coded? With a V code for history of cancer or code the breast cancer as if were active again. Which code would be correct, a V code for history of neoplasm with 198.3 or 198.3 as secondary and 174.9 as primary? Thanks Sherry R

  2. #2
    I don't have my book on me, so don't quote me on this, but I believe that you code it as: neoplasm, temporal lobe (or brain, if that's as specific as it gets), and it's the secondary site listing on the table. I think that you also code the history of malignant neoplasm, breast, to show where the primary cancer site was. (What a bum deal - breast cancer, then brain cancer??? Dang...). Go to the ICD-9 conventions, then go to the section with Chapter-specific guidelines (I think it's the second section), and go to Chapter 2, Neoplasms. It'll give you step-by-step directions on how to code this situation. Let me know if you need any more help!

  3. Default
    from your description the breast cnacer is in remission with no mention of recurrence so this would be coded as Histiory of breast cancer V10.3 the mets to the brain would be 198.3

    the sequencing would be 198.3, V10.3

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