ICD-10 Coding for History of Left Breast Cancer(Z85.3, Z90.12, Z08)
Complete ICD-10-CM coding and documentation guide for History of Left Breast Cancer. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Left Breast Cancer
Z85.3Primary Range
Personal history of malignant neoplasm of breast
Primary code for documenting history of breast cancer after treatment completion.
Acquired absence of left breast and nipple
Used when documenting the absence of the left breast post-mastectomy.
Encounter for follow-up examination after completed treatment for malignant neoplasm
Used for follow-up visits after cancer treatment.
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 completed treatment for breast cancer and there is no active disease. |
|
| Z90.12 | Acquired absence of left breast and nipple | Use when the patient has undergone a mastectomy of the left breast. |
|
| Z08 | Encounter for follow-up examination after completed treatment for malignant neoplasm | Use for follow-up visits post-treatment. |
|
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: ICD-10 code for history of left breast cancer
Essential facts and insights about History of Left Breast Cancer
Primary ICD-10-CM Codes for history of left breast cancer
Decision Criteria
clinical Criteria
- Patient has completed all cancer treatments and is in surveillance phase.
Applicable To
- History of breast cancer
Excludes
- Current breast cancer (C50.-)
Clinical Validation Requirements
- No evidence of active disease
- Completed treatment documented
Code-Specific Risks
- Misclassification as active cancer
Coding Notes
- Ensure documentation specifies 'no evidence of disease' and treatment completion.
Z90.12 - Acquired absence of left breast and nipple
Use when the patient has undergone a mastectomy of the left breast.
Applicable To
- Post-mastectomy status
Clinical Validation Requirements
- Documentation of mastectomy
Coding Notes
Always pair with Z85.3 when applicable.
Z08 - Encounter for follow-up examination after completed treatment for malignant neoplasm
Use for follow-up visits post-treatment.
Applicable To
- Follow-up visit after cancer treatment
Clinical Validation Requirements
- Follow-up visit documented
Coding Notes
Use as primary code if the visit is solely for surveillance.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for follow-up examination after completed treatment for malignant neoplasm
Z08Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Left Breast Cancer to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z85.3.
Impact
Clinical: Misleading patient records., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always specify 'left' or 'right' in documentation.
Impact
Reimbursement: Incorrect DRG assignment, affecting payment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and statistics.
Mitigation Strategy
Verify treatment completion and document 'no evidence of disease'.
Impact
Using active cancer codes for patients in remission.
Mitigation Strategy
Regular training on coding guidelines.
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 History of Left Breast Cancer, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Left Breast Cancer
Use these documentation templates to ensure complete and accurate documentation for History of Left Breast Cancer. These templates include all required elements for proper coding and billing.
Surveillance Visit Post-Mastectomy
Specialty: OncologyRequired Elements
- Patient history
- Treatment completion
- Current status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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