Oncology & Hematology Coding Alert

Reader Questions:

Make This History Code Dilemma a Thing of the Past

Published on Tue Aug 23, 2022

Question: We have a patient who is a breast cancer survivor, status post double mastectomy and taking tamoxifen. Can I code the cancer as current, since she is under treatment, or should I code Z85.3 for the history for breast cancer?

AAPC Forum Participant

Answer: Use of Z85.3 (Personal history of malignant neoplasm of breast) in this situation is dependent on whether the provider is prescribing the tamoxifen prophylactically after the cancer is fully terminated, or whether it is being used to treat an active cancer.

If the patient’s oncologist has prescribed the drug for treatment of active, ongoing breast cancer, then Z85.3 would not be appropriate, and it would be more correct to assign a code from C50.- (Malignant neoplasm of breast). This is consistent with ICD-10-CM guideline I.C.2.m, which states, “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.”

However, the same guideline also states, “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.”

So, if the treatment is not being aimed at the cancer site as the cancer has been completely eradicated, or if provider has prescribed tamoxifen prophylactically after there is no evidence of the condition, you would be correct in assigning Z85.3.

This is consistent with the Society of Gynecologic Oncology’s advice that “it is appropriate to use the personal history code… when the primary has been previously excised or eradicated from its site, there is no further treatment directed to that site, and there is no evidence of any existing primary malignancy at that site. … For patients on treatment, including maintenance, the primary cancer code should be used” (www.sgo.org/resources/ coding-qa-office-evaluation-management-note-questions/).