Final answer:
The appropriate diagnosis coding for the patient with a right lung metastasis and a history of breast cancer is C78.01 for the secondary malignant neoplasm of the right lung, and Z85.3 for the personal history of malignant neoplasm of the breast. The codes should be sequenced with C78.01 first, followed by Z85.3, to reflect the reason for the encounter and the relevant medical history.
Step-by-step explanation:
The coding for this patient's diagnoses should reflect the most current medical status and relevant medical history. After a thorough consideration of the documentation provided, the correct International Classification of Diseases (ICD) codes must be selected to accurately represent both the diagnosis of metastasis to the lung and the personal history of breast cancer. The correct ICD codes and their sequence are essential for proper medical billing and record-keeping.
The primary diagnosis, which is the reason for the current medical encounter, is the metastasis to the right lung. This is coded as C78.01, which refers to a secondary malignant neoplasm of the right lung. In addition, the patient's personal history of malignancy of the right breast, which has been previously treated, is relevant to the current encounter. This history is coded as Z85.3, which represents a personal history of malignant neoplasm of the breast. The correct sequencing of the codes places the primary reason for the encounter first, followed by additional codes that provide context about the patient's medical history.