General Surgery Coding Alert

Question: Following a mastectomy one year ago, the patient returns for a scar revision involving complex closure in the left axilla due to tightness and pain. The mastectomy resulted in a diagnosis of C50.212. The patient is still undergoing Tamoxifen therapy. Should we still code the diagnosis as C50.212, even though the tumor was removed?

Kansas Subscriber

Answer: For the diagnosis, you should code first the reason for the visit, 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 turn to a history code while the patient is still undergoing treatment

Depending on the size of the repair, the appropriate procedure code(s) would be something like 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm) and +13012 (Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure)).