Radi RadOnc slide11 - AAPC

Documentation Dissection

DIAGNOSIS: T2, N1a, M0, Stage IIB 2 ? Left Upper-outer quadrant of breast |1|.

CHIEF COMPLAINT: Here to discuss radiation therapy for her breast cancer.

PERTINENT HISTORY: The patient is a healthy 27-year-old white female with a strong family history of breast cancer who palpated a lump in her left breast early this year. She ended up having a mammogram and ultrasound in January showing a suspicious lesion that was biopsied and found to be an invasive ductal carcinoma, ER/PR-positive, HER-2/neu-positive. Given her strong family history she underwent genetic testing and was found to be BRCA positive |2|. PET/CT scanning showed no evidence metastatic disease. She underwent bilateral mastectomies with sentinel node procedure on the left breast Tumor was in the upper outer quadrant and at the time of mastectomy was found to have multifocal disease. The largest lesion surgically excised prior was approximately 2.8 cm. She had another smaller lesion away from this dominant mass. She did have a single positive sentinel node with extracapsular extension, A total of 7 additional nodes were removed - all negative for malignancy. She completed 6 Cycles of TCH chemotherapy and will continue on with Herceptin for a total of one year. She is here to discuss post-mastectomy radiotherapy.

PAST MEDICAL HISTORY: Left breast carcinoma, BRCA positive.

PRIOR SURGICAL HISTORY: 1. Left breast biopsy. 2. Left breast total mastectomy and right breast simple mastectomy 4/02/XX. 3. Obesity. 4. Left oophorectomy due to torsion.

CURRENT MEDICATIONS: Zyrtec.

ALLERGIES: Hydrocodone, Droperidol.

SOCIAL HISTORY: The patient lives with her parents. She has never smoked. Alcohol History: No.

FAMILY HISTORY: The patient has the following family history of cancer: Paternal grandmother with breast carcinoma, paternal aunt with ovarian carcinoma, paternal aunt with breast carcinoma, one cousin with BRCA positivity.

REVIEW OF SYSTEMS: Complete Review of Systems was obtained, as well as the patient's nurses' demographic sheet The patient presented with the following pertinent positives: Insomnia - No problems. Dyspnea - With exertion. Rashes - Hands. Alopecia H From chemo. Vascular Access ? Right chest Bard Port. Orientation - Oriented in three spheres of person I place, time. Memory Trouble concentrating after chemo. At risk of fall - No. ADL - No problems. Patient has problems with: - No. TB Screen: Cough for: - No. Otherwise complete Review of Systems obtained within normal limits.

PHYSICAL EXAM1NATION: GENERAL: A healthy white female here today with her parents.

VITAL SIGNS: P 92. T 97.8? (F). BP 155/95.

HEAD: Normocephalic and atraumatic. Diffuse alopecia present from chemotherapy.

LYMPH EXAM: No palpable cervical, supraclavicular, or infraclavicular adenopathy.

LUNGS: Clear to auscultation and percussion bilaterally.

CV: Regular rhythm and rate without murmurs, clicks or rubs.

ABDOMEN: Soft, nontender, and nondistended without hepatosplenomegaly.

EXTREMITIES: No clubbing, cyanosis, or edema. No pain to bony percussion.

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SKIN: Without rashes, bruising, or petechiae. LEFT CHEST WALL: Status post mastectomy without evidence of disease within the subcutaneous tissues. Axillae were negative bilaterally. ASSESSMENT: Stage IIB left breast cancer in the upper outer quadrant. PLAN: I had a long discussion today with the patient and her parents regarding her breast cancer. She has a multifocal tumor with that was node positive in a young female and due to this I feel that she would benefit from post-mastectomy radiotherapy. She also has extracapsular extension within the lymph node. I would plan on proceeding on with 28 fractions of radiotherapy to the chest wall and supraclavicular region followed by a 5-fraction boost to the scar. The expected benefits and potential risks of the treatment were discussed in detail including chance of lymphedema, chance of secondary malignancy in the future, heart damage. She understood the risks and was desirous of treatment. At this point we will proceed on with CT treatment planning and radiotherapy to begin in the future |3|. _____________________________________________________________

|1| This identifies the presenting diagnosis and location of the malignancy. |2| Additional diagnoses of family history of breast cancer and BRCA positive are documented. |3| Treatment plan is documented in this paragraph. _____________________________________________________________ What are the CPT? and ICD-10-CM codes reported? CPT? Code: 77263 ICD-10-CM Codes: C50.412, Z17.0, Z90.13, Z15.01, Z80.3 Rationales: CPT?: Unlike our other note, this patient does not have treatment of field set up or simulation; this is the Clinical Treatment Planning. Begin look up in the Index under Radiation Therapy. The first group of codes we will look for is Planning (77261?77263, 77299). Code 77263 is reported because the patient is having CT treatment and radiotherapy is planned. ICD-10-CM code: In the ICD-10-CM Table of Neoplasms, look for Neoplasm, neoplastic/breast/upper-outer quadrant C50.4-. In the Tabular List, the final character designates laterality. The code is C50.412 malignant neoplasm breast left upper-outer quadrant. The notes under category C50 indicates to use additional code to identify estrogen receptor status (Z17.0, Z17.1). Report Z17.0 for positive estrogen receptor (ER) status. Next, look in the ICD-10-CM Alphabetic Index for Absence/breast/acquired Z90.1-. Because the patient has recently had bilateral mastectomies, the absence of both breasts is reported with the absence of the breasts. In the Tabular List, fifth character 3 is reported for bilateral breasts. Next, look in the ICD-10-CM Alphabetic Index for Susceptibility to disease, genetic/malignant neoplasm/breast Z15.01. In the Tabular List, there is a note to also code for any family history which we report next. Look in the ICD-10-CM Alphabetic Index for History/family/malignant neoplasm/breast Z80.3. Verify code selection in the Tabular List.

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