Sequence This Radiation Sequela Scenario Successfully
Question: Our provider recently diagnosed a patient with lymphedema and began treating them for that condition. The patient was previously diagnosed with breast cancer, for which they underwent radiation treatment. They are now free of breast cancer, but the provider has documented that the lymphedema is a sequela of the treatment they received for the breast cancer. What is the correct way to document this? New York Subscriber Answer: Radiation treatment can be a cause of lymphedema, as the radiation can damage the lymph vessels to the point where they cannot adequately drain lymph fluid, leaving the body prone to infection. In your particular case, the lymphedema is considered a sequela of the treatment, and you would code the diagnosis first with I89.0 (Lymphedema, not elsewhere classified). Then, you will need to document the prior radiation treatment as the cause of the lymphedema, which you will do with Y84.2 (Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure). As the breast cancer is in remission and is no longer being treated, you could also add Z85.3 (Personal history of malignant neoplasm of breast) to the record. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
