Wiki Help with Coding - 'm just checking my aInswers

[MrsAllen07]

'm just checking my aInswers before I code them, Please help me verify.

A patient who underwent a modified radical mastectomy of the left breast six
months earlier because of carcinoma now has metastasis to the bone. She
was admitted for a transfusion of packed cells to treat aplastic anemia,
probably due to her treatment by chemotherapy. She was discharged with
hemoglobin of 11.5 and will be followed as an outpatient. Patient history
significant for C-section in 1988, HTN, Insulin dependent DM with CKD stage 2.
She quit smoking 10 years ago and has been prescribed medical marijuana to
assist with the effects of the chemo.


1. Aplastic anemia secondary to chemotherapy. 2. Metastatic bone cancer. 3. E code for adverse effect of the chemo. 4. Personal history of breast cancer. 5. Family history of breast cancer.

 

[mitchellde]

Since the documentation states probably due to chemo you cannot code as being due to the chemo. So code aplastic anemia, bone mets, and because it does not state the breast is no longer being treated code the active breast cancer and no E code, and family history of breast cancer is not documented. I would also include the diabetes with manifestation code and the CKD.

 

[Dhaneshmurali]

Anemia due to chemotherapy

Hi,


I need some clarifications from your note.

1. Anemia due to chemotherapy

There is no confirm causual relationship between anemia and chemotherapy. The word 'probably' denotes is qualifying condition.

2. Metastatic bone cancer.

Metastatic cancer code need additional code for primary site (breast cancer) or unspecified code (199.1).

If the patient currently receiving treatment for breastcancer means, then no need to code history code.
3. what about diagnosis codes for DM, HTN,CKD2?

 

[mitchellde]

Probably does not denote a relationship look at your coding guidelines anything documented as probably , possibly or rule out indicates uncertainty which cannot be coded.
You stated breast cancer now with mets to the bone which indicates the breast is primary, primary can be either active or history. So you code the bone mets(198.5) and active breast cancer (174.9). The aplastic anemia cannot be coded as due to chemo since it is not certain. Yes I would code the HTN and the DM with manifestation as I indicated.