A 52 year old white female with two distinct lesions of the right breast one 05

A 52 year old white female with two distinct lesions

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A 52-year old white female with two distinct lesions of the right breast, one (0.5 cm) in the upper outer quadrant and a second (1.5 cm) in the lower outer quadrant; path report indicates both lesions are malignant C50.411 Malignant neoplasm of upper-outer quadrant of right female breast C50.511 Malignant neoplasm of lower-outer quadrant of right female breast Explanation : This patient has two distinct malignant lesions of right breast in adjacent quadrants. Because the lesions are not contiguous, two codes are reported. Patient with primary prostate cancer with metastasis to lungs admitted for wedge resection of mass in right lung C78.01 Secondary malignant neoplasm of right lung C61 Malignant neoplasm of prostate Explanation : Since the admission is for treatment of the lung metastasis, the secondary lung metastasis is sequenced before the primary prostate cancer. Patient is admitted for treatment of anemia in advanced colon cancer C18.9 Malignant neoplasm of colon, unspecified D63.0 Anemia in neoplastic disease Explanation : Even though the admission was solely to treat the anemia, this guideline indicates that the code for the malignancy is sequenced first. A 56-year-old Hispanic male with grade II follicular lymphoma involving multiple lymph node sites referred for blood transfusion to treat anemia due to chemotherapy D64.81 Anemia due to antineoplastic chemotherapy C82.18 Follicular lymphoma grade II, lymph nodes of multiple sites T45.1X5A Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter Explanation : The code for the anemia is sequenced first followed by the code for the malignant neoplasm and lastly the code for the adverse effect.
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Guidelines and Examples Chapter 2. Neoplasms ICD-10-CM 2017 Chapter 2. Neoplasms 434 ICD-10-CM 2017 3) Management of dehydration due to the malignancy When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy. 4) Treatment of a complication resulting from a surgical procedure When the admission/encounter is for treatment of a complication resulting from a surgical procedure, designate the complication as the principal or first-listed diagnosis if treatment is directed at resolving the complication. d. Primary malignancy previously excised When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code.
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