Documenting a patient's breast cancer history? Learn about accurate clinical documentation, medical coding (ICD-10), and best practices for recording history of breast cancer, previous breast cancer, or prior breast malignancy. This resource provides information for healthcare professionals on capturing complete details for patients with a breast cancer diagnosis history, ensuring appropriate care and accurate medical records.
Also known as
Personal history of malignant neoplasm of breast
Indicates a past diagnosis of breast cancer.
Acquired absence of breast following mastectomy
Status post mastectomy; may indicate prior breast cancer.
Acquired absence of breast following other surgery
Status post breast surgery, possibly related to cancer history.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the breast cancer personal history or family history?
Personal History
Is there any evidence of current breast cancer?
Family History
Code family history of breast cancer (Z80.3).
When to use each related code
| Description |
|---|
| Prior breast cancer diagnosis. |
| Personal history of in situ breast cancer. |
| Family history of breast cancer. |
Missing laterality (right, left, bilateral) for history of breast cancer can lead to inaccurate reporting and claims.
Confusing personal history of breast cancer with family history can impact risk assessment and treatment plans.
Failing to specify whether the history is of in situ or invasive breast cancer affects staging and treatment coding.
Q: How does a patient's history of breast cancer, including tumor characteristics and treatment response, inform current treatment decisions for a new breast cancer diagnosis or recurrence?
A: A comprehensive history of breast cancer is crucial for guiding treatment decisions in cases of new primary breast cancers or recurrence. Factors such as the initial breast cancer subtype (e.g., ER/PR status, HER2 status, grade), stage at diagnosis, prior treatments received (surgery, chemotherapy, radiation, endocrine therapy, targeted therapy), response to those treatments, and any long-term side effects experienced provide essential context. For example, if a patient with a history of ER-positive breast cancer experiences a recurrence, endocrine therapy resistance should be considered, potentially warranting alternative treatment strategies. Similarly, the presence of specific genetic mutations identified during the initial diagnosis can inform targeted therapy options for subsequent cancers. Careful consideration of past tumor characteristics alongside the current presentation allows for personalized treatment plans that maximize efficacy while minimizing potential risks. Explore how integrating comprehensive patient history into treatment planning tools can improve outcomes in recurrent or new breast cancers.
Q: What are the key elements of a thorough breast cancer history taking, including specific questions to ask about previous breast cancer diagnosis, treatment, and family history to assess risk and personalize management strategies?
A: A comprehensive breast cancer history involves collecting detailed information on several key aspects. First, ascertain the date of the original diagnosis, stage, tumor characteristics (ER, PR, HER2 status, grade, size, lymph node involvement), and type of surgery performed (lumpectomy, mastectomy, reconstructive procedures). Next, document all administered treatments, including chemotherapy regimens, radiation details (dose, area treated), endocrine therapy duration, and any targeted therapies used, along with their efficacy and side effects. Thoroughly explore the patient's response to each treatment modality. Inquire about any persistent or late effects experienced, such as lymphedema, neuropathy, or cardiac issues. A detailed family history of breast, ovarian, or other related cancers should also be obtained, including the age of onset and any known genetic mutations. This comprehensive history allows for personalized risk assessment, guides surveillance strategies, and informs treatment selection for subsequent breast cancer occurrences or other related conditions. Consider implementing a standardized breast cancer history template to ensure consistent and thorough data collection.
Patient presents with a history of breast cancer. Initial diagnosis was made on [Date of Diagnosis] at age [Age at Diagnosis]. The patient's breast cancer diagnosis included [Specific Diagnosis e.g., invasive ductal carcinoma, ductal carcinoma in situ, lobular carcinoma in situ] in the [Laterality e.g., left, right] breast. Receptor status was determined to be [Receptor Status e.g., ER positive, PR positive, HER2 positive, triple negative]. Staging at diagnosis was [Stage e.g., Stage I, Stage IIA, etc.] according to the TNM classification. Treatment history includes [Treatment details e.g., lumpectomy, mastectomy, sentinel node biopsy, axillary lymph node dissection, chemotherapy regimen, radiation therapy, hormone therapy, targeted therapy specifying medications, dates, and cycles]. Current surveillance plan includes [Surveillance plan e.g., mammogram frequency, oncologist follow-up, specific blood tests]. Patient reports [Current symptoms or concerns related to previous breast cancer or treatment e.g., no current concerns, lymphedema symptoms, pain, recurrence concerns]. Physical examination findings include [Relevant physical exam findings e.g., well-healed surgical scar, no palpable masses, normal lymph node exam]. Assessment includes history of breast cancer, currently [Status e.g., in remission, no evidence of disease, with metastatic disease]. Plan includes [Plan e.g., continued surveillance per guidelines, referral to oncology, further imaging]. This documentation supports the ICD-10 code Z85.3 (personal history of malignant neoplasm of breast) and relevant medical billing codes for evaluation and management services.