ICD-10 Code Z85.3

ICD-10-CM code Z85.3 indicates “personal history of malignant neoplasm of the breast.” This code is part of the Z85 category in International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM), which covers personal history of malignant neoplasms. Z85.3 specifically focuses on patients who have a past medical history of breast cancer but are not currently undergoing active treatment for the condition.

The Z85.3 code documents a patient's history of breast cancer. It is used for ongoing medical care and monitoring, as a history of breast cancer can influence future health risks and treatment decisions. The code is used in medical records to ensure that the patient's history is accurately captured, which impacts preventive care, surveillance, and management of any long-term complications that may arise from previous cancer treatments.

While Z85.3 itself does not pertain to current symptoms, the context in which this code might be used is important. Patients with a history of breast cancer may not exhibit symptoms related to the cancer itself but may experience side effects or symptoms related to past treatments such as chemotherapy, radiation, or surgery. These can include:

Several other ICD-10 codes are related to Z85.3, each representing different aspects of cancer history or current cancer diagnoses. These include:

When using Z85.3, ensure the code is applied in the correct context. Use this code for patients who have a documented history of breast cancer. Do not use this code for patients currently undergoing treatment for breast cancer or those who are newly diagnosed. 

Once the patient completes active cancer treatment and the provider documents no presence of cancer, they may assign this code. 

If the patient is on a tamoxifen regime, the provider should clarify whether it is to prevent further cancers or to suppress a current cancer. In the event the regime is to prevent further cancers, code the most current cancer episode as a history of cancer. If it is to suppress a current episode of cancer, the cancer is considered active and should be coded to an active malignant neoplasm code. This treatment may occur for years following first diagnosis. 

Several pitfalls can occur when coding with Z85.3:

For accurate coding and documentation, consider the following resources:

ICD-10 code Z85.3 documents a patient's history of breast cancer. Accurate coding ensures that healthcare providers have a comprehensive understanding of the patient's medical history, which is important for ongoing care and monitoring. By understanding the appropriate use, common pitfalls, and available resources, medical coders can effectively use Z85.3 to enhance patient care and medical record accuracy.

Tebra’s EHR+ gives you quick searches and Systematized Nomenclature of Medicine (SNOMED) field names for efficient code documentation. Plus, Tebra automatically saves ICD-10 to SNOMED mapping for future searches, streamlining your workflow.

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