Coding Tip: Breast Cancer
Breast Cancer Coding Tips
Current Vs. Historical Breast Cancer
Do not use the phrase “history of” to describe a current primary breast cancer. In diagnosis coding, “history of” means the condition is historical and no longer exists as a current problem.
In the final impression, do not document a simple statement of “breast cancer” to describe a historical primary breast cancer that was previously excised or eradicated and for which there is no active treatment and no evidence of disease or recurrence.
In this scenario, it is appropriate to document “history of breast cancer,” along with details of past diagnosis and treatment.
Breast cancer site(s) – primary and secondary
- Document whether current breast cancer is primary, secondary or in situ. Also, document:
- Laterally (right or left)
- The specific site of primary cancer, including the location within breast (areola, nipple, upper outer quadrant, central portion, etc.)
- The specific secondary site(s)
Treatment Plan
- Document a clear and concise plan of care.
- Clearly indicate whether current therapy represents:
- Active treatment of current breast cancer
- Palliative treatment of current breast cancer
- Surveillance of a historical breast cancer to monitor for recurrence
- When adjuvant therapy is used, clearly state its purpose (whether the goal of adjuvant therapy is curative, palliative or preventive).
- If referrals are made or consultations requested, indicate to whom or where the referral is made or from whom consultation advice is requested.
- Document when the patient is to be seen again.
Coding Breast Cancer as Current
Coding Breast Cancer as Historical
Breast cancer is coded as historical (Z85.3) after the breast cancer has been excised or eradicated, there is no active treatment directed to the breast cancer and there is currently no evidence of disease or recurrence.
