The patient was admitted for biopsy of an enlarged lymph node in the area of the left axilla. The patient has a past medical history of breast cancer with a mastectomy of the left breast 1 year ago. The patient is no longer receiving any therapy for her cancer. A needle biopsy was done. The pathology report showed normal lymphatic tissue with no evidence of metastatic spread.Final Diagnosis: Lymphadenopathy left axilla; metastasis ruled out Procedure: Needle core biopsy axillary lymph node
A)R59.9, Z85.3, Z90.12, 07B63ZX
B)R59.1, Z85.3, Z90.12, 07B63ZZ
C)R59.0, Z85.3, Z90.11, 07B53ZX
D)R59.0, Z85.3, Z90.12, 07B63ZX

Question

Quizplus · Accepted Answer

R59.0 (enlarged lymph nodes), Z85.3 (personal history of malignant neoplasm of breast), and Z90.12 (acquired absence of left breast and nipple) are all appropriate codes for this case. The procedure was a needle core biopsy of the axillary lymph node so the appropriate PCS code is 07B63ZX. Choice A is incorrect because R59.9 indicates unspecified lymphadenopathy, which is not accurate since the pathology report ruled out metastasis. Choice B is incorrect because R59.1 indicates generalized lymphadenopathy, which is not mentioned in the case description. Choice C is incorrect because Z90.11 is for acquired absence of right breast and nipple, which is not mentioned in the case description.

The Patient Was Admitted for Biopsy of an Enlarged Lymph