History of Breast Cancer ICD 10 Guide:
What is Breast Cancer?
Breast cancer is the uncontrolled growth of the body cells in the human breast. The type of cancer depends on the type of cells involved.
When a patient visits any doctor for breast screening, the doctor asks about the personal or family history of cancer or any other associated breast condition, e.g., change in breast size, discharge from nipple or areola, lump or pain, etc.
The history of any disease is a significant determinant of the diagnosis and the chances of its reoccurrence. The history-taking is considered an essential part of medical evaluation.
The following are the necessary points you will find in the patient’s medical report regarding breast cancer while coding breast cancer:
The primary reason for the patient seeking healthcare services is a Presenting Complaint. For example, a patient may seek help for a painful lump in the breast as a Presenting Complaint.
History of Presenting Complaint/Illness
The physician needs to get as much information as possible about the patient’s complaint. For example, the physician asks about the site of the lump, when it developed or was noticed by the patient, whether it is soft or hard, does the pain radiate or not, what are the other associated symptoms, changes in the lump with time and any triggers or relieving factors, etc.
Past Medical History
The physician asks the patient about the previous or any other medical problems. It includes any other ongoing medical issues, prior procedures, or surgeries.
In the case of breast cancer, the following information can be helpful:
History of early onset of menstruation and late menopause, hormone replacement therapy, and no breastfeeding. Any previous breast lumps or cancer. Any allergies or reactions are also documented.
The physician gathers information about the drugs and their dosages that the patient is taking and how often he is taking them. The drug history of breast cancer emphasizes using oral contraceptives and hormone replacement therapy, as they increase cancer risk.
The patient’s family history is significant because it tells about certain illnesses associated with genes. Cardiac conditions, diabetes, and many other diseases that run in families can be ruled out by taking the family history. While taking a family history of breast cancer, the patient might be asked if any close relative has a history of breast or ovarian cancer, and if they have, at which age they developed it.
The social history tells more about the patient’s habits, surroundings, and activities of daily living. The doctor can find out if the patient smokes, drinks alcohol, or uses any other illegal substances. The physician can also get information about the patient’s surroundings and guardians to ensure they are addressed.
Review of Systems
A short review of each body system helps ensure that the evaluation is done correctly and that nothing is left. These systems include Central Nervous System (CNS), Respiratory System, Cardiovascular System (CVS), Gastrointestinal System (GI), Genitourinary System, and Musculoskeletal System.
Summary of History
The physician reviews the history and repeats it before the patient for any correction or further addition to the previous history. The physician must address the patient’s concerns and discover their hopes and expectations from the healthcare providers.
The physician must answer the patient’s questions and take their feedback on the interaction with the physician himself and the other healthcare providers.
ICD-10 coding system:
World Health Organization (WHO) has introduced an updated system of coding termed the ICD-10 coding system. This system is designed to code diseases, diagnoses, treatments, and other healthcare-related services. It makes the billing and documentation of insurance services handy and efficient.
ICD-10 coding for the history of breast cancer:
Code for personal history of malignant neoplasm of the breast:
The ICD-10 code for personal history of malignant neoplasm of the breast is Z85.3. This code is grouped within the Diagnostic Related Group (MS-DRG v40.0). It includes the conditions classifiable to Diagnosis code group C50 series.
C50- is the default code for the Malignant neoplasm of the breast, and it contains the following subcodes:
C50.0- Malignant neoplasm of nipple and areola
C50.1- Malignant neoplasm of the central portion of the breast
C50.2- Malignant neoplasm of the upper-inner quadrant of the breast
C50.3- Malignant neoplasm of the lower inner quadrant of the breast
C50.4- Malignant neoplasm of the upper outer quadrant of the breast
C50.5- Malignant neoplasm of the lower outer quadrant of the breast
C50.6- Malignant neoplasm of axillary tail of the breast
C50.8- Overlapping lesion of the breast
C50.9- Unspecified malignant neoplasm of the breast
The above code excludes personal history of benign neoplasm. It also excludes the personal history of carcinoma in situ.
After the treatment of malignant neoplasm, any follow-up examination should be coded first (Z08) before mentioning the code of malignant neoplasm. The Coders use the following additional codes while coding for the personal history of malignant neoplasm:
Additional codes that can go as secondary diagnosis codes are:
Code F10 is used to identify alcohol use and dependence.
Code Z77.22 is used to identify exposure to environmental smoke and tobacco.
Code Z87.891 is additionally used to mention the history of tobacco dependence.
Code F17 and code Z720 identify tobacco dependence and tobacco use, respectively.
Any occupational exposure to environmental tobacco smoke is identified using the code Z57.31.
Codes for the personal history of in-situ neoplasm of the breast:
The diagnosis code for in-situ neoplasm of the breast is Z86.000. It includes conditions classifiable to code D05. Code D05 identifies carcinoma in situ of the breast. Its components are as follows:
D05.0-Lobular carcinoma in situ
D05.1- Intraductal carcinoma in situ
D05.7- Other carcinomas in situ of the breast
D05.9- Unspecified carcinoma in situ of the breast
Code for the family history of malignant neoplasm of the breast:
The diagnosis code for the family history of malignant neoplasm of the breast is Z80.3. It covers the family history of female and male breast cancer, before and after the age of 45 years, and the history of breast cancer in a first and second-degree relative. Like the code for personal history of malignant neoplasm, this code also includes the conditions classified to code C50 (mentioned above).
Code for the family history of malignant neoplasm, unspecified:
The diagnosis code for the family history of malignant neoplasm unspecified is Z80.9. It includes the family history of cancer, heritable or inherited cancer and malignancy, and the history of Muir-torrè syndrome (a genetic condition causing the colon to be more prone to cancer). The conditions classifiable to code C80.1 are included in this code.
Code C80.1 is used for primary malignant neoplasm, unspecified. It applies to:
- Cancer NOS
- Unknown cancer site (primary)
- Carcinoma unspecified site (primary)
- Malignancy unspecified site (primary)
Code for the personal history of malignant neoplasm, unspecified:
The personal history of malignant neoplasm, unspecified, is coded under the diagnosis code Z85.9.
Code for the secondary malignant neoplasm of the breast:
The diagnosis code for the secondary malignant neoplasm of the breast is C79.81. It includes cancer metastatic to the left and right breast and cancer metastatic to bilateral breasts.
Other associated conditions and their coding:
It is the diagnosis code for the personal history of breast implant removal. It includes the history of the left and right breast implants removed and the history of bilateral breast implants removed.
This code is for the encounter for screening mammogram for malignant neoplasm of the breast. It also includes the screening mammogram done in high-risk patients with a family history of cancer.
This code is for the personal history of irradiation. It includes a history of radiation exposure, brachytherapy, chest irradiation, external beam radiation therapy, radiation therapy for cervical cancer, radiation therapy to the breast area, exposure to radiation in the physical and occupational environment, and personal history of exposure to therapeutic radiation.
It is the diagnosis code for the family history of malignant neoplasm of the testis.
It is the diagnosis code for the personal history of malignant neoplasm of the testis.
It is the diagnosis code for the family history of malignant neoplasm of the prostate.
It is the diagnosis code for the personal history of malignant neoplasm of the prostate. It also includes the history of cancer of the prostate, the history of radiation therapy for prostate cancer, and the history of malignant neoplasm of the prostate.
Armed Forces Health Surveillance Center. Incident diagnoses of cancers and cancer-related deaths, active component, U.S. Armed Forces, 2005-2014. Medical Surveillance Monthly Report (MSMR). 2016 July; 23(7): 23-31. 2American Cancer Society. Cancer Facts & Figures 2019. Atlanta: American Cancer Society; 2019.
Guoqiao Zheng, Jan Sundquist, Kristina Sundquist, and Jianguang Ji; Family history of breast cancer as a second primary malignancy in relatives: a nationwide cohort study; BMC Cancer (2021) 21:1210
Hannah R. Brewer, Michael E. Jones, Minouk J. Schoemaker, Alan Ashworth, Anthony J. Swerdlow; Family history and risk of breast cancer: an analysis accounting for family structure; Breast Cancer Res Treat (2017) 165:193–200;
Breast Cancer ICD-10 Code Reference Sheet; AmbryGenetics.
ICD 10 VERSION :2019 ; WORLD HEALTH ORGANISATION.