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
Personal history of malignant neoplasm of breast
History of breast cancer.
Malignant neoplasm of breast
Current breast cancer (if applicable, not history).
Acquired absence of right breast
May be relevant if mastectomy performed due to cancer.
Family history of malignant neoplasm
Relevant for family history, not personal history.
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?
When to use each related code
Description |
---|
Right Breast Cancer History |
Personal Hx of Breast Ca |
Hx of Invasive Ductal Ca |
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].