ICD-10 Coding for Breast Cancer in Remission(Z85.3, Z08)
Complete ICD-10-CM coding and documentation guide for Breast Cancer in Remission. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Breast Cancer in Remission
Z85.3Primary Range
Personal history of malignant neoplasm of breast
Used to indicate a history of breast cancer when there is no active disease.
Encounter for follow-up examination after completed treatment for malignant neoplasm
Used for follow-up visits after treatment completion to monitor for recurrence.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z85.3 | Personal history of malignant neoplasm of breast | Use when the patient has no active breast cancer and is not receiving curative treatment. |
|
| Z08 | Encounter for follow-up examination after completed treatment for malignant neoplasm | Use for follow-up visits post-treatment to monitor for recurrence. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: How is breast cancer in remission coded?
Essential facts and insights about Breast Cancer in Remission
Primary ICD-10-CM Codes for breast cancer in remission
Decision Criteria
clinical Criteria
- No evidence of active disease
coding Criteria
- Patient is not receiving curative treatment
Applicable To
- History of breast cancer
Excludes
- Current breast cancer (C50.XXX)
Clinical Validation Requirements
- No evidence of disease on imaging
- Completed curative treatment
- Adjuvant therapy is prophylactic
Code-Specific Risks
- Incorrectly used when active treatment is ongoing
Coding Notes
- Ensure documentation clearly states no active disease and treatment intent.
Z08 - Encounter for follow-up examination after completed treatment for malignant neoplasm
Use for follow-up visits post-treatment to monitor for recurrence.
Applicable To
- Follow-up after cancer treatment
Excludes
- Active cancer treatment (Z51.XXX)
Clinical Validation Requirements
- Follow-up visit documented
- No active treatment ongoing
Coding Notes
Ensure follow-up visit is clearly documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Hormone therapy
Z79.890Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Breast Cancer in Remission to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z85.3.
Impact
Clinical: Misinterpretation of patient status., Regulatory: Potential for audit issues., Financial: Incorrect billing and reimbursement.
Mitigation Strategy
Clarify therapy intent in documentation., Use specific language regarding treatment goals.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Verify treatment intent and use C50.XXX if treatment is curative.
Impact
Using Z85.3 when active treatment is ongoing.
Mitigation Strategy
Verify treatment intent and document clearly.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Breast Cancer in Remission, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Breast Cancer in Remission
Use these documentation templates to ensure complete and accurate documentation for Breast Cancer in Remission. These templates include all required elements for proper coding and billing.
Surveillance Visit
Specialty: OncologyRequired Elements
- Patient history
- Current status
- Adjuvant therapy
- Surveillance plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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