Jenneta Posted Wed 21st of October, 2015 15:40:52 PM
Patient came to Radiation Oncology clinic for follow up after being treated with radiation therapy for malignant neoplasm of the breast. Doctor indicates no evidence of disease 24 months post radiation therapy and also documents that patient is on Tamoxifen and should continue taking pill. I need help with the Diagnosis
I'm thinking it should be :
Z08- FOLLOW UP AFTER TREATMENT FOR MALIGNANT NEOPLASM
Z85.3- PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST.
I didnt use codes from chapter 2 (ICD10-CM) or C codes because doctor states there is no evidence of disease.
Jenneta Posted Wed 21st of October, 2015 15:49:16 PM
I am also considering
Z79.810-LONG TERM (CURRENT) USE OF TAMOXIFEN
Z85.3-PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST
SuperCoder Answered Fri 23rd of October, 2015 03:10:03 AM
Thanks for your question.
To code this scenario, use ICD-10 code
Jenneta Posted Mon 26th of October, 2015 11:51:24 AM
I read somewhere and it states that if the patient is currently taking Tamoxifen that you should use the C codes eg. C50.911 which corresponds to the Malignant Neoplasm as the primary Dx and Z79.810 as secondary Dx. There reason for this is that Tamoxifen is being used as a treatment. :-(
SuperCoder Answered Tue 27th of October, 2015 01:39:00 AM
In some cases, physician prescribing these drugs for prophylactic use after the completion of cancer treatment. This is for prevention from future reoccurrence. In the above scenario, patient is taking tamoxifen and there is no evidence of malignancy, so we cannot use C codes to code this. We will use only history code for these type of scenario.
Jenneta Posted Thu 29th of October, 2015 15:36:18 PM
Thank you for clarifying.
SuperCoder Answered Fri 30th of October, 2015 00:16:29 AM