General Surgery Coding Alert

Question: A year after undergoing a mastectomy, the patient returns for a scar revision that includes a complex closure in the left underarm area because of discomfort and pain. The mastectomy led to a C50.212 diagnosis. The patient continues to receive tamoxifen treatment. Despite the tumor’s removal, should the diagnosis still be coded as C50.212?

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Answer: For the diagnosis, you should first code the reason for the visit, which is Z48.817 (Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue). Then, report a more specific code, such as L90.5 (Scar conditions and fibrosis of skin).

Because the patient is still undergoing treatment for the cancer, you should report C50.212 (Malignant neoplasm of upper-inner quadrant of left female breast) as the second diagnosis. You would not use a history code while the patient is still undergoing active treatment. However, if the patient is taking Tamoxifen to prevent future cancer instead of the treated cancer, personal history of breast cancer is reported instead.

Based on the extent of the repair, examples of the appropriate procedure code(s) would be 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm) and +13102 (Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure)).

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC