ICD-10 Coding for History of Mastectomy(Z85.3, Z90.1-)
Complete ICD-10-CM coding and documentation guide for History of Mastectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Mastectomy
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 cancer treatment and is under surveillance. |
|
| Z90.1- | Acquired absence of breast | Use to indicate the absence of breast tissue post-mastectomy. |
|
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 mastectomy
Essential facts and insights about History of Mastectomy
Primary ICD-10-CM Codes for history of mastectomy
Decision Criteria
clinical Criteria
- Patient has completed all cancer treatments and shows no evidence of disease.
Applicable To
- History of breast cancer
Excludes
- Current breast cancer (C50.-)
Clinical Validation Requirements
- Pathology reports confirming no residual disease
- Imaging results showing no evidence of disease
- Completion of active treatment
Code-Specific Risks
- Incorrectly used with active treatment codes
Coding Notes
- Ensure documentation specifies no current evidence of disease.
Z90.1- - Acquired absence of breast
Use to indicate the absence of breast tissue post-mastectomy.
Applicable To
- Status post mastectomy
Clinical Validation Requirements
- Surgical history indicating mastectomy
- Documentation of laterality
Coding Notes
Specify laterality using Z90.11, Z90.12, or Z90.13.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Mastectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z85.3.
Impact
Clinical: Incomplete patient records, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Always specify laterality, Review surgical history
Impact
Reimbursement: Incorrect DRG assignment, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate patient records
Mitigation Strategy
Use C50.- until all treatments are completed.
Impact
Using Z85.3 when active treatment is ongoing
Mitigation Strategy
Verify treatment status before coding
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 Mastectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Mastectomy
Use these documentation templates to ensure complete and accurate documentation for History of Mastectomy. These templates include all required elements for proper coding and billing.
Oncology Surveillance Visit
Specialty: OncologyRequired Elements
- Patient history
- Treatment completion date
- Current surveillance status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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