Find comprehensive information on documenting a history of testicular cancer. This resource covers clinical documentation, medical coding (ICD-10 C62), testicular cancer staging, tumor markers (AFP, HCG, LDH), orchiectomy, retroperitoneal lymph node dissection (RPLND), and surveillance after testicular cancer treatment. Learn about capturing relevant past medical history, including dates of diagnosis, treatment details, and current disease status for accurate healthcare records and optimized billing.
Also known as
Personal history of malignant neoplasm of testis
Indicates a past diagnosis of testicular cancer.
Malignant neoplasm of testis
Classifies current testicular cancers by specific type and location.
Persons encountering health services
May be used for follow-up or surveillance after cancer treatment.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the testicular cancer currently active?
When to use each related code
Description |
---|
Testicular cancer |
Germ cell tumor, testis |
Leydig cell tumor |
Missing documentation specifying right, left, or bilateral involvement creates coding ambiguity for Z85.4.
Incorrectly coding active cancer (C62.-) when patient has history of cancer (Z85.4) leads to overbilling and quality issues.
Lack of detail about type and stage impacts accurate Z85.4 sub-coding for data analysis and reimbursement.
Patient presents with a history of testicular cancer, diagnosed on [Date of Diagnosis] as [Specific Histologic Type, e.g., seminoma, non-seminoma, mixed germ cell tumor]. Initial presentation included [Symptoms at presentation, e.g., painless testicular mass, testicular swelling, scrotal heaviness, back pain]. Initial tumor markers were [e.g., AFP, beta-hCG, LDH] at [Values at diagnosis]. Staging workup, including [Imaging studies performed, e.g., scrotal ultrasound, CT scan of abdomen and pelvis, chest x-ray], revealed [Stage at diagnosis, e.g., Stage I, Stage II, Stage III]. Initial treatment consisted of [Treatment received, e.g., radical orchiectomy, retroperitoneal lymph node dissection (RPLND), chemotherapy regimen specified]. Patient reports [Current status, e.g., no evidence of disease, persistent disease, recurrence]. Current surveillance includes [Ongoing monitoring plan, e.g., physical exam, tumor marker monitoring, imaging studies] with frequency of [Frequency of follow-up]. Patient denies [Pertinent negatives, e.g., new or worsening symptoms, pain, swelling]. Physical exam reveals [Findings, e.g., normal scrotal examination, palpable mass, lymphadenopathy]. Assessment: History of testicular cancer, [Current status, e.g., in remission, with persistent disease, recurrent]. Plan: Continue current surveillance plan. Patient education provided regarding the importance of adherence to the follow-up schedule and reporting any new or recurrent symptoms. Differential diagnoses considered at initial presentation included [Differential diagnoses, e.g., epididymitis, orchitis, testicular torsion, spermatocele, hydrocele]. ICD-10 code: C62.9 (Malignant neoplasm of testis, unspecified) or specify other C62 code as appropriate.