Find comprehensive information on History of Breast Carcinoma, including clinical documentation, medical coding, and healthcare resources. Learn about relevant ICD-10 codes, Z85.3, breast cancer staging, past breast cancer diagnosis, and subsequent care. This resource offers valuable insights for healthcare professionals, coders, and patients seeking information on managing a history of breast carcinoma. Explore treatment options, long-term surveillance, and support resources for individuals with a prior diagnosis of breast cancer.
Also known as
Personal history of malignant neoplasm of breast
History of breast cancer.
Acquired absence of breast
Absence of breast following mastectomy.
Personal history of chemotherapy
History of chemotherapy, often used for breast cancer treatment.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the breast carcinoma currently present?
Yes
Do NOT code as history. Code the active carcinoma (C50.-).
No
Is there personal history of in situ carcinoma?
When to use each related code
| Description |
|---|
| History of breast cancer |
| Personal history of breast neoplasm |
| Family history of breast cancer |
Missing or unclear documentation of the affected breast (right, left, or bilateral) can lead to coding errors and claims rejections.
Incorrectly coding active breast cancer (C50.-) when the patient has a history of breast cancer (Z85.3) impacts reimbursement and data accuracy.
Lack of documentation specifying the type and stage of the original breast cancer can hinder accurate coding for subsequent encounters.
Patient presents with a history of breast carcinoma. This includes a confirmed diagnosis of invasive ductal carcinoma, stage IIA, diagnosed in October 2022. The patient underwent a lumpectomy with sentinel lymph node biopsy at that time, revealing two positive sentinel nodes. Subsequent adjuvant chemotherapy with docetaxel and cyclophosphamide was completed in April 2023, followed by radiation therapy to the chest wall and regional lymph nodes. The patient is currently on endocrine therapy with anastrozole. She reports no current signs or symptoms suggestive of recurrence, such as breast pain, nipple discharge, skin changes, or palpable masses. Physical examination reveals a well-healed surgical scar at the lumpectomy site, with no lymphedema or erythema noted. Axillary examination is unremarkable. Current assessment focuses on surveillance for breast cancer recurrence, including ongoing endocrine therapy management and monitoring for potential adverse effects. Plan includes continued anastrozole, routine mammographic surveillance, and ongoing clinical breast exams. Patient education regarding signs and symptoms of recurrence and the importance of adherence to endocrine therapy was reinforced. Medical coding includes ICD-10 code Z85.3 for personal history of malignant neoplasm of breast and appropriate Z codes for aftercare following breast cancer treatment. Billing will reflect evaluation and management services for established patient with history of breast cancer. Keywords: Breast cancer, breast carcinoma, history of breast cancer, invasive ductal carcinoma, lumpectomy, sentinel lymph node biopsy, adjuvant chemotherapy, radiation therapy, endocrine therapy, anastrozole, recurrence surveillance, mammogram, clinical breast exam, patient education, ICD-10 Z85.3, medical coding, medical billing, electronic health records, EHR.