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I am auditing oncology charts and one of the coders insists on using V45.71 when the patient has had a partial mastectomy. I believe it is not appropriate since she still has part of her breast still. Any thoughts?
According to the Coders Desk Reference V45.71 is only intended for use when the condition itself is reported at the diagnosis or problem. Usually a patient with a partial mastectomy will have another reason for additional testing - i/e pain at site, new mass / calcs. If there is no reason I have always been told to code for high risk screening or the reason for the parital mastectomy, especially if the test is a follow-up for the mastectomy.