Question: Patients who have breast cancer, and who have had the malignancy removed, will frequently be given adjuvant therapy such as Arimidex or tamoxifen after they have finished chemo or radiation. In these situations, do I use an active cancer diagnosis code, or should I look to a history of neoplasm Z code instead?
AAPC Forum Participant
Answer: What code you report in this situation will depend on how your provider has documented the patient’s condition and the purpose of the treatment. If the patient’s cancer has been completely eradicated and the patient is receiving the treatment prophylactically, then you will use a history code such as Z85.3 (Personal history of malignant neoplasm of breast). However, if cancer is still present and the drug is being used to augment therapy for active cancer, then you will use an appropriate active cancer diagnosis code from C50.- (Malignant neoplasm of breast).
This is consistent with ICD-10-CM guideline I.C.2.m, which tells you, “When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.”
Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
