October is Breast Cancer Awareness Month

doctor explaining to patient

Published October 2024

Documentation and Coding Tips for Providers

Every year, breast cancer accounts for about 30% of all new cancer cases in U.S. women. As Breast Cancer Awareness month is upon us, it is a perfect time to review best practices in coding and documentation. MVP is committed to supporting Providers by offering tips that not only ensure compliance in coding and documentation, but also directly affects patient care and outcome tracking.

Documentation tips

Document the cancer sites
  • Laterality: left, right, bilateral breast(s)
  • Type and stage: Document whether the cancer is ductal, lobular, or another type, and document the stage
  • Specific primary and secondary sites: Including the location within the breast (areola, nipple, upper outer quadrant, central portion, etc.)
Document the treatment plan
  • Clearly outline recommended treatments, including excisions, radiation, chemotherapy, hormone therapy, or active/routine surveillance
  • When adjuvant therapy is used, document the purpose, whether it is curative, palliative, prophylactic/preventive
Current versus Historical Breast Cancer
  • Documentation should clearly show whether the cancer is active/current or historical
  • Breast Cancer should be documented as “history of” when the cancer has been excised or eradicated, the cancer no longer exists as a current problem, there is no active treatment or surveillance, and there is no evidence of disease or recurrence.
  • Document personal history of malignant neoplasm to indicate the former site of the malignancy
When a primary malignancy has been excised, but additional treatment is directed to the site:
  • Continue to document the primary malignancy until treatment is complete and no evidence of cancer remains
Avoid unspecific coding
  • Avoid non-specific codes when more detailed options are available (e.g., C50.9, Malignant neoplasm of unspecified site of unspecified female breast.)

Breast Cancer Code Set

Malignant Neoplasm of the Breast C50.0 – C50.9
Carcinoma in Situ of the Breast D05.0 – D05.92
Personal history of malignant neoplasm of the breast Z85.3
Secondary malignant neoplasm of the breast C79.81
Encounter for screening mammogram for malignant neoplasm of the breast Z12.31

Please refer to the ICD-10-CM coding manual for an all-inclusive list of codes. If you have any questions, please contact Christine Sutherland at CSutherland@mvphealthcare.com or Julie Eisen at JEisen@mvphealthcare.com.

Closing Gaps in Care

Review other articles in this issue regarding closing gaps in care.

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