AHA Coding Clinic® for ICD-9 - 2011 Issue 2; Ask the Editor

Prophylactic Bilateral Mastectomy due to Positive BRCA Mutation Status Post Lumpectomy

A 63-year-old female with a history of left breast carcinoma treated with left breast lumpectomy and radiation therapy was recently diagnosed with BRCA1 genetic mutation. The patient is admitted at this time for bilateral prophylactic mastectomy, latissimus dorsi flap, and placement of tissue expander, as well as reconstruction. Since the patient has a personal history of breast cancer, would the bilateral mastectomy be considered prophylactic or therapeutic? How would this case be coded? ...

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