Wiki DX Z40.01

[mmertens61@aol.com]

New patient consultation with out breast cancer or breast issues. Patient is BRACA positive and requesting a prophylactic breast surgery. Is it appropriate to use DX Z40.01?

 

[carlystur]

That code says to use additional code to indicate the risk factor, which you might look at Z5.01 for.

 

[xXxPARAGONxXx]

That code says to use additional code to indicate the risk factor, which you might look at Z5.01 for.

@carlystur means Z15.01.

Primary: Genetic susceptibility to malignant neoplasm of breast (ICD-10-CM Z15.01)
Secondary: Encounter for prophylactic removal of breast (ICD-10-CM Z40.01)

 

[csperoni]

I would not use Z40.01 for the consultation to discuss a prophylactic mastectomy. I would use it on the actual surgery. For the visit, consider Z71.89 along with Z15.-- and/or family history codes. Z15.-- cannot be primary diagnoses per the guidelines:
Z15 Genetic susceptibility to disease
Genetic susceptibility indicates that a person has a gene that increases the risk of that person developing the disease.
Codes from category Z15 should not be used as principal or first-listed codes. If the patient has the condition to which he/she is susceptible, and that condition is the reason for the encounter, the code for the current condition should be sequenced first. If the patient is being seen for follow-up after completed treatment for this condition, and the condition no longer exists, a follow-up code should be sequenced first, followed by the appropriate personal history and genetic susceptibility codes. If the purpose of the encounter is genetic counseling associated with procreative management, code Z31.5, Encounter for genetic counseling, should be assigned as the first-listed code, followed by a code from category Z15. Additional codes should be assigned for any applicable family or personal history.

 

[carlystur]

Yes. I did not mean to suggest that Z15.01 should be first as the "Use Additional" guideline does not mean Primary, but "in addition to" the current dx code. I am not real familiar with all of the Z codes other than the ones that I use most often for Body Mass Index and long term use of specified drugs, such as antibiotics, aspirin, anti-coagulants, etc.