Facebook tracking pixelHistory of Right Breast Cancer - AI-Powered ICD-10 Documentation
Z85.3
ICD-10-CM
History of Right Breast Cancer

Find comprehensive information on documenting and coding a history of right breast cancer. This resource covers relevant medical coding guidelines, including ICD-10 codes (Z85.3, C50), clinical documentation best practices for history of right breast malignancy, and healthcare terminology related to past breast cancer diagnosis, treatment, and surveillance. Learn about proper medical record documentation for patients with a history of breast cancer in the right breast, focusing on recurrence prevention, long-term care, and patient management.

Also known as

Past Breast Cancer, Right
Previous Right Breast Cancer

Diagnosis Snapshot

Key Facts
  • Definition : Prior diagnosis of cancer in the right breast tissue.
  • Clinical Signs : May include lump, skin changes, nipple discharge, or no signs if treated.
  • Common Settings : Oncology clinics, primary care, breast imaging centers.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z85.3 Coding
Z85.3

Personal history of malignant neoplasm of breast

History of breast cancer.

C50.-

Malignant neoplasm of breast

Current breast cancer (if applicable, not history).

Z90.11

Acquired absence of right breast

May be relevant if mastectomy performed due to cancer.

Z80.-

Family history of malignant neoplasm

Relevant for family history, not personal history.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the right breast cancer currently active?

  • Yes

    Is there mets documented?

  • No

    Personal history of right breast ca?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right Breast Cancer History
Personal Hx of Breast Ca
Hx of Invasive Ductal Ca

Documentation Best Practices

Documentation Checklist
  • History of right breast cancer: Document laterality, stage, and treatment.
  • Confirm diagnosis basis: Pathology report, imaging, or clinical findings?
  • Specify date of original diagnosis for accurate staging and coding.
  • Document any recurrence or metastasis for proper treatment planning.
  • Record hormone receptor status (ER, PR, HER2) to guide therapy.

Mitigation Tips

Best Practices
  • Code Z85.3 for personal history of breast cancer.
  • Document laterality (right) and specific histology.
  • Ensure complete staging and treatment details in the chart.
  • Query physician for clarity if documentation is vague.
  • Regularly audit records for accurate breast cancer coding.

Clinical Decision Support

Checklist
  • Confirm laterality: Right breast documented
  • Validate diagnosis: Pathology report reviewed
  • Stage documented: TNM or equivalent system
  • Date of diagnosis clearly recorded
  • Treatment history documented

Reimbursement and Quality Metrics

Impact Summary
  • Reimbursement and Quality Metrics Impact Summary: History of Right Breast Cancer
  • Keywords: Medical Billing, Coding Accuracy, ICD-10 Z85.3, Hospital Reporting, Breast Cancer, Reimbursement, Quality Metrics, Case Mix Index, Value-Based Care
  • Impact 1: Accurate Z85.3 coding maximizes appropriate reimbursement.
  • Impact 2: Correct coding impacts cancer registry data and quality reporting.
  • Impact 3: History of cancer codes influence CMI and risk adjustment models.
  • Impact 4: Proper documentation supports value-based care initiatives for survivors.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code Z85.3 for history of breast ca
  • Laterality: 'Right' is crucial
  • Document date of original dx
  • Confirm no current active disease
  • Consider stage at diagnosis

Documentation Templates

Patient presents with a history of right breast cancer.  Initial diagnosis of invasive ductal carcinoma of the right breast was confirmed on [Date of Diagnosis] via [Diagnostic method, e.g., core needle biopsy] revealing [Histological grade] with [mention of ER, PR, and HER2 receptor status, e.g., ER-positive, PR-negative, HER2-negative].  Original tumor size was [Size] cm.  The patient underwent [Surgical procedure, e.g., lumpectomy with sentinel lymph node biopsy] on [Date of Surgery].  Pathology report indicated [Number] of [Total number] sentinel lymph nodes were positive for malignancy.  Post-surgical staging was [Stage, e.g., TNM stage].  Adjuvant therapy included [Type of therapy, e.g., chemotherapy regimen, radiation therapy to the right breast or chest wall, hormonal therapy].  Patient is currently [Status, e.g., disease-free, in remission, with recurrent disease].  Current visit is for [Reason for visit, e.g., surveillance, symptom evaluation, management of treatment side effects].  Patient reports [Patient-reported symptoms].  Physical exam reveals [Relevant physical exam findings].  Assessment: History of right breast cancer, [Current status, e.g., stable, improving, worsening].  Plan: [Plan of care, e.g., continue surveillance, order imaging studies, refer to oncology, prescribe medication].  Patient education provided regarding [Relevant topics, e.g., importance of follow-up, management of side effects, breast self-exam].  Return to clinic in [Timeframe].