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ICD 10 Coding Alert

Reader Question:

Wait for this Report Before Coding

Question: The op note states that a patient undergoing a lumpectomy has a history of DCIS. How should I code the diagnosis?

Texas Subscriber

Answer: Ideally, you would wait for the pathology report and code the final diagnosis for the lumpectomy.

Without a final diagnosis, you’ll have to code the “ordering diagnosis” or the reason for the test. You don’t mention any other signs or symptoms from the op report, such as a perceived “lump” or an abnormal mammogram. With the information you have, you’re left with coding the personal history of ductal carcinoma in situ (DCIS).

The appropriate ICD-10 code would be Z86.000 (Personal history of in-situ neoplasm of breast).

Don’t confuse the personal history code with codes for the condition, which are:

  • D05.10 (Intraductal carcinoma in situ of unspecified breast)
  • D05.11 (Intraductal carcinoma in situ of right breast)
  • D05.12 (Intraductal carcinoma in situ of left breast)

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