History of breast neoplasm on Tamoxifen

Coding history of breast neoplasm on Tamoxifen

Created Aug 2017
Reviewed Dec 2019

Query

A patient is admitted for breast reconstruction due to previous mastectomy for breast cancer, patient is still on Tamoxifen. Do we need to code the breast cancer status as additional diagnosis? If yes, is this a current cancer or history?

Response

Research indicates that tamoxifen is a hormone treatment for breast cancer.  Tamoxifen is used to treat breast cancer when surgery is not appropriate, and as adjuvant treatment of oestrogen-receptor positive early breast cancer, as it reduces the risk of breast cancer recurrence, and the risk of developing a second breast cancer.

Tamoxifen can be prescribed for 5-10 years depending on the risk of cancer recurrence.

A patient on Tamoxifen alone does not meet the criteria for coding as an additional diagnosis.  Coders need to review the clinical record to determine the patient’s medical history.  Following this, coders then need to refer to the appropriate coding standards to determine if current breast cancer or history of cancer meets the criteria for coding as an additional diagnosis. Refer to ACS 0236 Neoplasm coding and sequencing for guidelines when the primary malignancy should be coded as current, and ACS 0002 Additional diagnoses – family and personal history and certain conditions influencing health status (Z80-Z99) for coding personal history of malignant neoplasm.

In this case, as the patient was admitted for a breast reconstruction due to previous mastectomy for breast cancer as per ACS 0002 Additional diagnoses – family and personal history and certain conditions influencing health status (Z80-Z99) it is appropriate to assign Z85.3 Personal history of malignant neoplasm of breast as an additional diagnosis as the history is directly relevant to the current episode of care.

Reference: Breast Cancer Foundation NZ – Hormonal therapy

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