Home Health ICD-9/ICD-10 Alert

Question: Our patient was admitted to home health following a radical left mastectomy for malignant breast cancer. We will be providing surgical aftercare, education and monitoring of the disease process, and wound and drain care, including dressing changes. She will receive chemotherapy as an outpatient. How should we code for this patient?

California Subscriber

Answer: Code for this patient as follows:

• M1020a: V58.42 (Aftercare following surgery for neoplasm);
• M1021b: 174.9 (Malignant neoplasm of female breast, unspecified); and
• M1021c: V58.31 (Encounter for change or removal of surgical wound dressing).

You’re providing aftercare following surgery to treat your patient’s cancer, so V58.42 is your principal diagnosis code. 

Next, list 174.9 to indicate your patient’s breast cancer. Yes, she had a mastectomy to treat the cancer, but she continues to receive chemotherapy, so it’s appropriate to report a cancer code rather than a history of cancer code. You’ll note that even in ICD-9, you have options for selecting a more specific code to report your patient’s breast cancer, so if the medical record provides more information, be sure to select a more specific code.

Finally, list V58.31 to indicate that you will be providing wound care. Your drain care is included in the aftercare code.

In ICD-10, for this patient you would report the 

following codes:

• M1021a: Z48.3 (Aftercare following surgery for neoplasm);
• M1023b: C50.912 (Malignant neoplasm of unspecified site of left female breast); and
• M1023c: Z48.01 (Encounter for change or removal of surgical wound dressing).