Oncology & Hematology Coding Alert

Question: A patient had a lumpectomy. When would it be appropriate for me to use a personal history code and is Z98.890 the correct code to use?

AAPC Forum Participant

Answer: Your code choice in this situation is correct, and Z98.890 (Other specified postprocedural states) is the best code you can use in the patient’s record.

Whether you should use it for a specific encounter, however, depends on whether the patient’s history of the lumpectomy is relevant to that encounter. ICD-10-CM guideline I.B.19.d tells you that a Z code “may be assigned as appropriate to further explain the reasons for presenting for healthcare services … or provide additional information relevant to a patient encounter.” This echoes chapter-specific guideline I.C.21.4, which tells you “history codes are … acceptable on any medical record regardless of the reason for visit,” as they contain “important information that may alter the type of treatment ordered.”

And remember: The same chapter-specific guideline tells you that a diagnosis code that represents “the reason for the encounter … should be sequenced first and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es).”