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For other articles and previous issues click here. February 14, 2005 Coding
for Breast Cancer Breast cancer occurs when malignant cells form in breast tissues. The following are the common types of breast cancer: • ductal carcinoma, which begins in the cells of the breast ducts; • lobular carcinoma, which begins in the lobes or lobules of the breast; and • inflammatory breast cancer, which occurs when the cancer cells block the lymph vessels in the skin and causes the breast to be warm, red, and swollen. Primary malignant breast cancer in the female is classified to ICD-9-CM category 174 and includes Paget’s disease of the breast and nipple. A fourth-digit subcategory identifies the site of the malignancy as follows: • 174.0, Nipple and areola • 174.1, Central portion • 174.2, Upper-inner quadrant • 174.3, Lower-inner quadrant • 174.4, Upper-outer quadrant • 174.5, Lower-outer quadrant • 174.6, Axillary tail • 174.8, Other specified sites of female breast, including ectopic sites, inner breast, lower breast, midline of the breast, outer breast, upper breast, and contiguous or overlapping sites of the breast whose point of origin cannot be determined • 174.9, Female breast, unspecified More than one code from category 174 may be assigned if the patient has breast cancer in different sites in one or both breasts. However, if a patient has bilateral breast cancer of the same site, only one diagnosis code should be assigned. It is inappropriate to assign a diagnosis code twice on the same admission (AHA Coding Clinic for ICD-9-CM, 1989, fourth quarter, page 11). Although rare, males may be diagnosed with breast cancer, which is classified to category 175. Code 175.0 is assigned for malignant neoplasm in the nipple and areola of the male breast, and code 175.9 is assigned for all other specified sites or unspecified sites of the male breast. Malignant neoplasm of the breast, male or female, documented as carcinoma in situ is classified to code 233.0. Assign code 217 for a benign neoplasm of the breast. The following are the appropriate code assignments for a diagnosis of a neoplasm of the skin of the breast: • 172.5, Malignant melanoma of skin of breast • 173.5, Primary malignant neoplasm of skin of breast • 198.2, Secondary malignant neoplasm of skin of breast • 232.5, Carcinoma in situ of skin of breast • 216.5, Benign neoplasm of skin of breast Symptoms • lump or mass in the breast or armpit; often painless, the breast lump is firm to hard and usually has irregular borders; • abnormal, clear, or bloody discharge from the nipple; • retraction or indentation of the nipple; • change in the size or shape of the breast; and • redness or pitting of the skin over the breast. Other conditions that may cause changes or lumps in the breast include fibrocystic disease of breast (610.1), breast cyst (610.0), fibroadenomas of the breast (217), mastitis (611.0), and microcalcification that is identified by mammography (793.81). Diagnosis • Needle biopsy or fine-needle aspiration biopsy (85.11) removes breast tissue using a thin needle. • Incisional breast biopsy (85.12) removes part of a lump or suspicious tissue. • Excisional breast biopsy. The code assignment will depend on the specific procedure performed. If only a portion of the lump was removed, assign code 85.12. However, code 85.21 is assigned if the entire lesion or lump were excised. There are several different approaches in which a biopsy may be performed such as stereotactic, mammotome, core, and wire localization. While these biopsies utilize different techniques, they are essentially needle biopsies and will be classified to code 85.11 unless the documentation supports that an open biopsy (85.12) or lumpectomy (85.21) was performed. Treatment • Lumpectomy (85.21) removes only the lump plus a surrounding area of normal tissue. • Partial or segmental mastectomy (85.23). Code 85.22 will be assigned if the procedure is documented as excision of quadrant of breast. In both of the above procedures (sometimes documented as breast sparing), area lymph nodes may be excised. Lymph nodes in the breast area are found around the axilla, above the collarbone, and in the chest. If area lymph nodes are excised, an additional procedure code may be assigned. Simple excision of lymph nodes is classified to code 40.29. Assign code 40.23 for simple excision of axillary lymph nodes. Code 40.3 is assigned if the procedure is documented as regional lymph node excision with excision of lymphatic drainage area, including skin, subcutaneous tissue, and fat regardless of site. Sometimes a sentinel lymph node biopsy is performed. Breast cancer typically first spreads to axillary lymph nodes. The sentinel node is the first node to receive the drainage from breast tumors and therefore the first to develop cancer. When the sentinel lymph node is identified by a radioactive solution, it is removed and tested for cancer. Assign code 40.23 for a sentinel lymph node biopsy (AHA Coding Clinic for ICD-9-CM, 2002, second quarter, page 7). The following are types of mastectomies that may be performed: • Simple mastectomy (85.41 for unilateral or 85.42 for bilateral) is the complete excision of the breast. • Modified radical mastectomy (85.43 for unilateral or 85.44 for bilateral) is the complete excision of the breast including the axillary lymph nodes, but not the pectoral muscle. • Radical mastectomy (85.45 for unilateral or 85.46 for bilateral) is the complete excision of the breast, including the regional lymph nodes, pectoral muscle, and adjacent tissues. The patient may also have to undergo a combination of radiation therapy, chemotherapy, hormone therapy, and biological therapy before or after surgery. Coding and sequencing for breast cancer are dependent upon the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding. — This information was prepared by Audrey Howard, RHIA, and Vicki Sippel, RHIA, of 3M Health Information Systems (800-367-2447), a leading supplier of coding and classification systems to nearly 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information. |
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