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Question: In 2019, a patient had a bilateral mastectomy and bilateral breast reconstruction. The patient then came back requesting further surgery to improve breast symmetry. The patient is not currently undergoing treatment. Should we bill this with Z85.3 or C50.411 based on Coding Guidelines Section I.C.2.m, since it is an additional surgery for a malignancy?

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Answer: Even though ICD-10-CM Guideline I.C.2.m tells you that “when a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed,” you should not use C50.411 (Malignant neoplasm of upper-outer quadrant of right female breast) for this encounter.

The reason in this situation is twofold. First, you should not regard surgery to improve breast symmetry following a mastectomy and breast reconstruction as further treatment. Second, your own note tells you that the patient is not currently undergoing treatment for breast cancer.

Consequently, you should follow the next part of 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.” That means, you would be correct in coding Z85.3 (Personal history of malignant neoplasm of breast) for this encounter.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC