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It becomes very confusing on coding Breast Cancer or Prostrate Cancer when still on medications, but no indication of disease. Please see example below. Patient was seen by physician on 10/15/2015.
ONC HX: Multicentric right breast cancer T2N1M0. Date of diagnosis 11/20/2008. ER 95%, PR 87%, HER2/neu negative by FISH. Tumor size 3.2 cm. Right mastectomy with axillary sentinel biopsy 01/21/2009 by Dr. Adjuvant chemotherapy with AC x4 cycles followed by Taxol q. week x12 cycles 02/24/2009 to 08/04/2009, Arimidex 1 mg p.o. daily date of start is 09/2009.
IMPRESSION: Stage II breast cancer, ER/PR positive, currently on Arimidex. Excellent tolerance
Continue Arimidex 1 mg p.o. daily
Would this be coded as history of breast cancer or as active breast cancer?
Barbara
ONC HX: Multicentric right breast cancer T2N1M0. Date of diagnosis 11/20/2008. ER 95%, PR 87%, HER2/neu negative by FISH. Tumor size 3.2 cm. Right mastectomy with axillary sentinel biopsy 01/21/2009 by Dr. Adjuvant chemotherapy with AC x4 cycles followed by Taxol q. week x12 cycles 02/24/2009 to 08/04/2009, Arimidex 1 mg p.o. daily date of start is 09/2009.
IMPRESSION: Stage II breast cancer, ER/PR positive, currently on Arimidex. Excellent tolerance
Continue Arimidex 1 mg p.o. daily
Would this be coded as history of breast cancer or as active breast cancer?
Barbara
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