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The patient was admitted for prophylactic breast removal. The patient has a strong family history of breast cancer, and the patient has severe fibrocystic disease in both breasts, making breast exam difficult. The patient was taken to the OR, and a bilateral simple mastectomy was performed. The patient recovered with no problems. The pathology report showed no evidence of malignancy.Final Diagnosis: Family history of breast cancer; severe fibrocystic diseaseProcedure: Bilateral simple mastectomy

a.Z40.8, N60.11, N60.12, 0HTV0ZZ
b.Z40.01, Z80.3, N60.11, N60.12, 0HTV0ZZ
c.Z40.01, Z80.3, N60.19, 0HTT0ZZ, 0HTU0ZZ
d.N60.11, N60.12, Z40.01, 0HTT0ZZ, 0HTU0ZZ

1 Answer

4 votes

Final answer:

The correct ICD-10 codes for the prophylactic bilateral simple mastectomy due to family history of breast cancer and severe fibrocystic disease are Z40.01, Z80.3, N60.19, 0HTT0ZZ, and 0HTU0ZZ.

Step-by-step explanation:

Understanding Prophylactic Breast Removal Coding

The scenario presents a patient with a significant family history of breast cancer and severe fibrocystic disease undergoing a prophylactic bilateral simple mastectomy. When coding for this procedure, the correct ICD-10 codes need to incorporate the reason for surgery (prophylactic measure), the family history, the specifics of the breast disease, and the exact procedure performed.

In this case, the following ICD-10 codes should be considered:
Z40.01 is used for Prophylactic organ removal for preventing the disease, which in this case is breast cancer due to family history.
Z80.3 denotes a family history of malignant neoplasm of the breast.
N60.19 represents Diffuse cystic mastopathy, unspecified breast, covering the patient's fibrocystic condition.

Finally, the codes 0HTT0ZZ and 0HTU0ZZ represent Resection of Right Breast, Open Approach, and Resection of Left Breast, Open Approach, respectively, which indicate that a bilateral simple mastectomy was performed.

Therefore, the most accurate and appropriate ICD-10 codes for this case appear to be option c which includes Z40.01, Z80.3, N60.19, 0HTT0ZZ, and 0HTU0ZZ, describing all aspects of the case from the prophylactic surgery due to family history to the condition of the breast followed by the detailed procedure carried out.

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