Oncology & Hematology Coding Alert

Question: A patient underwent a bilateral mastectomy after having breast cancer of the left upper inner breast, which was coded to C50.212. The patient is now on adjuvant hormonal therapy (Tamoxifen) for five years. Is the specific location of the breast cancer still coded as C50.212, or should it be C50.919 since the cancer is no longer in the left upper inner breast?

Also, if the provider documents the stage as T4N2M0, should I code the lymph mets as well?

AAPC Forum Participant

Answer: Even though the mastectomy removed the patient’s cancer, the location of the cancer did not change after the surgery. So, C50.212 (Malignant neoplasm of upper-inner quadrant of left female breast) is still correct and a better choice than the unspecified C50.919 (Malignant neoplasm of unspecified site of unspecified female breast) code in this situation.

Additionally, as the patient is still undergoing treatment for the original cancer, an active cancer code would be preferable to a history code such as Z85.3 (Personal history of malignant neoplasm of breast).

As for the stage designation stated, T4 means the tumor has spread, N2 means cancer cells exist in the lymph nodes, and M0 means there is no sign the cancer has spread. Therefore, without a clear notation of the presence of cancer cells in the lymphatic tissue, metastasis (mets) cannot be assumed without additional documentation. However, it would be appropriate, though not ideal, to code C77.9 (Secondary and unspecified malignant neoplasm of lymph node, unspecified) if the provider has not specified lymph mets and not specified which lymph nodes were affected. This would be a good opportunity to go back to the provider and discuss the best way to document such conditions moving forward.