# Breast BX: DX Documented 174.9-Path report no cancer



## Trendale (Mar 20, 2009)

Hello,can someone help me with the following scenario?: ( I don't code BX's that often)

Indication for the procedure: The patient presented to my office with an erythema edema of the left breast with nipple retraction. Findings were highly suspicious for inflammatory  breast Ca and the patient was scheduled for a BX.
The first part I need help with codes. An oval incision was made to include  some skin with BX and we went down , taking down some of the breast tissue as well. The BX was passed off the table. We now used Tru-Cut needle BX and did biopsies of all the quandrants of the breast. This will be sent together with the main BX. 
As I understand it, if the physcian excises a portion of the mass use 19101, and I  also coded 19100 for the needle BX.

Secod Part is my biggest concern. In the office note, the physcian stated the patient was highly suspiious for breast cancer, and for that office encounter, the DX went out as a 174.1. ( you do not code suspcious, likely, proabble for office) The path report came back with no Carcinoma identified. 
As I understand it, do not document and code a definitive DX without path results.  For the office note, the symptoms should have been coded, in which in this case it was inflammatory breast DZ-611.0  and 782.3
174.1 should not be on the patient's record at all baed on the path results.

Thanks!


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## FTessaBartels (Mar 20, 2009)

*Diagnosis of 174.1*

Unfortunately for your patient she now has a cancer diagnosis in her medical / insurance record that will follow her forever. 

F Tessa Bartels, CPC, CEMC


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