Pathology/Lab Coding Alert

Question: The pathologist examined a right breast specimen from the upper inner quadrant of a 50 year old female patient and diagnosed infiltrating ductal carcinoma. The clinician also ordered testing for BRCA1, BRCA2 and CHEK2 mutations, which returned BRCA1 positive. What are the correct diagnosis code(s) for this case? Should we use the family history code because BRCA1 increases the hereditary risk of breast cancer?

Georgia Subscriber

Answer: You should report first the cancer diagnosis as C50.211 (Malignant neoplasm of upper-inner quadrant of right female breast).

For the BRCA1 positive results, you should not use a family history code such as Z84.81 (Family history of carrier of genetic disease) because the test results are for the patient, and you have no indication that a family member also has the mutation or breast cancer.

Do this: In addition to the primary code for the cancer, you should report Z15.01 (Genetic susceptibility to malignant neoplasm of breast). ICD-10-CM also directs you to report an additional code, if applicable, “for any personal history of malignant neoplasm (Z85.-).”