Guidelines for coding breast cancer and treatment
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The guidelines for coding Neoplasms are below. Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm , it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. If malignant, any secondary metastatic sites should also be determined. For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast , codes for each site should be assigned.
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American Cancer Society Releases New Breast Cancer Guideline
ISDH: Breast & Cervical Cancer Home
Physician documentation has always supported accurate diagnosis code reporting, but never more so than with the transition to ICDCM codes. Specific terminology and the use of key words and phrases is essential, especially with terms such as "aftercare" and "follow-up," which physicians may use interchangeably. The aftercare Z code should not be used if treatment is directed at a current, acute disease. The diagnosis code is to be used in these cases. If the reason for the encounter is more than one type of antineoplastic therapy, code Z
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Early Breast Cancer Treatment
Active cancer codes support that a malignancy is present or has been excised but treatment is ongoing, e. Document will state patient has:. A personal history of malignancy code supports a past diagnosis, by a qualified health professional of cancer, that no longer exists, AND the patient is not receiving active treatment, but has the potential for recurrence, and therefore may require continued monitoring and surveillance. Diagnostic mammogram along with an ultrasound exam confirmed a 1.
This summary discusses primary epithelial breast cancers in women. The breast is rarely affected by other tumors such as lymphomas, sarcomas, or melanomas. Refer to the following PDQ summaries for more information on these cancer types:.
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