tci General Surgery Coding Alert - 2002 Issue 6

Reader Question: Diagnosis for Prophylactic Mastectomy

Question: The patient had a breast biopsy that revealed atypical ductal dysplasia. The surgeon scheduled a bilateral simple mastectomy (19180-50) at the request of the patient, who has a family history of breast cancer. What are the correct diagnosis codes for atypical ductal dysplasia and family history of breast cancer? Vermont SubscriberAnswer: The diagnosis codes that support the simple mastectomy can be arranged to provide an easy-to-follow trail of medical necessity. The primary diagnosis is the dysplasia, which is a neoplasm of uncertain behavior (238.3) and provides medical necessity for the mastectomy of the breast with the neoplasm...

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