ICD 10 Coding Alert

Reader Question:

Document Smoking History in This Malignant Neoplasm Encounter

Question: Our physician diagnosed a malignant bronchial neoplasm for a patient who has been a chronic smoker. How do we report this and the patient's history of smoking?

West Virginia Subscriber

Answer: From your description, it seems that your physician diagnosed a malignant neoplasm in the main bronchus.

ICD-10-CM offers options specific to location in the right or left bronchus:

  • C34.01 -  Malignant neoplasm of right main bronchus
  • C34.02 - Malignant neoplasm of left main bronchus.

When your physician does not document the laterality in case of malignant neoplasm of the bronchus, you should report code C34.00 (Malignant neoplasm of unspecified main bronchus).

Do not miss tobacco exposure: Because your physician has documented the habit of smoking in the patient, you should also submit code Z72.0 (Tobacco use) or Z87.891 (Personal history of nicotine dependence) depending on the explanation of tobacco use and timing.

Below are additional exposure to tobacco choices in ICD-10-CM. Assign the correct ICD-10-CM code as supported by the physician's documentation:

  • Exposure to environmental tobacco smoke (Z77.22)
  • Exposure to tobacco smoke in the perinatal period (P96.81)
  • Occupational exposure to environmental tobacco smoke (Z57.31)
  • Nicotine dependence (F17.200 - F17.299).


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