Question

what is the professional code and the icd-10-cm codes for this case? CHIEF COMPLAINT: Breast cancer, visit to discuss options This established patient is a 61-year-old woman with a small amount of palpable biopsy-proven cancer in the upper outer right breast. Physical examination is consistent with a nonpalpable mass. The screening mammograms, ultrasound, and reports are reviewed and I agree with the radiologist that there is a suspicious 5-mm lump in the upper outer right breast. The patient prefers to receive her health information with verbal discussion, which I had with her and her husband for over half of this 1-hour visit and she was given a great deal of written literature for review. I reviewed the anatomy of the breast and where in the breast cancer begins. I discussed the goals of breast cancer treatment and her treatment options. One surgical option is to undergo a lumpectomy with a sentinel axillary lymph node dissection to be followed by radiation treatment. That option was discussed with her in great detail including the advantages and disadvantages. The other surgical option is to undergo a mastectomy with or without breast reconstruction with a sentinel axillary lymph node dissection and radiation treatment would not be required. That option was also discussed with her in great detail including the advantages and disadvantages. I emphasized that either option would resolve in the same chance of being cured of the breast cancer, so this will be her choice to make. I explained that a sentinel lymph node dissection would be performed, which is a way to remove only 2 or 3 lymph nodes. I discussed how the sentinel lymph node would be identified and specifically the blue dye injected into the breast could cause staining of the skin for several months. If the sentinel lymph node contains metastatic cancer, then 15 more lymph nodes would be removed. Complications of surgery include a small chance of infection, bleeding requiring another operation or arm problems such as arm swelling, arm soreness, arm stiffness or arm numbness, etc. The chance and severity of the arm problems depends on the number of lymph nodes removed. Approximately 15% of the time, a second operation would be needed and this occurs if a sentinel lymph node contains metastatic cancer and that is not diagnosed until the permanent sections are available or if a lumpectomy margin is involved with cancer. The patient told me she would be interested in breast conservation, which certainly gives a good choice for big breasted woman with a small cancer. This will require needle localization on the morning of surgery and I also explained what that is. I discussed what she could expect during her recovery from surgery. Preoperatively, I will schedule a breast MRI and a right axillary ultrasound and I discussed the reasons for those studies. I will also schedule a consultation with the radiation oncologist and postoperatively, I will schedule a consultation with a medical oncologist as the patient may be a candidate for adjuvant hormonal treatment. She had questions, which were answered. She indicated no barriers to learning and wishes to complete the preoperative workup and schedule her surgery.

Answer 1

In the present scenario, the 61-year-old woman

CHIEF COMPLAINT:

Breast cancer, visit to discuss options This established patient with a small amount of palpable biopsy-proven cancer in the upper outer right breast. Physical examination is consistent with a nonpalpable mass. The screening mammograms, ultrasound, and reports are reviewed and I agree with the radiologist that there is a suspicious 5-mm lump in the upper outer right breast.

The treatment options are lumpectomy with a sentinel axillary lymph node dissection to be followed by radiation treatment.

The other surgical option is to undergo a mastectomy with or without breast reconstruction with a sentinel axillary lymph node dissection and radiation treatment would not be required.

The patient is willing for the lumpectomy and she wishes to complete the pre-operative check-up after hearing the advantages and disadvantages of each procedure

Thus here we can apply the ICD-10 code as C50.4 Indicates the malignant Neoplasms at the upper-outer quadrant of the breast.