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 examination 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 disease.Procedure: 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

Question

Quizplus · Accepted Answer

The patient underwent prophylactic mastectomy due to a strong family history of breast cancer and severe fibrocystic disease in both breasts. The correct code for prophylactic mastectomy is Z40.01. The patient also has a family history of breast cancer which is coded using Z80.3. The fibrocystic breast disease is coded using N60.11 for the right breast and N60.12 for the left breast. The procedure performed was a bilateral simple mastectomy which is represented by 0HTV0ZZ. Therefore, the best code choices are Z40.01, Z80.3, N60.11, N60.12, and 0HTV0ZZ.

The Patient Was Admitted for Prophylactic Breast Removal