AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2020 Issue 3; Ask the Editor

Refusal of Adjuvant Therapy for Breast Carcinoma Status Post Mastectomy

A patient, who was diagnosed with an infiltrating ductal carcinoma of the right breast of overlapping sites, presents for an outpatient follow-up visit after previously undergoing an excisional lumpectomy with sentinel lymph node dissection. Margins on the pathology report were clear and the sentinel lymph node was benign. During the follow-up visit, the oncologist recommended adjuvant endocrine therapy. However, the patient refused adjuvant therapy because her primary care physician indicated the benefits would be minimal. What is the appropriate code assignment for this visit since the patient is without evidence of any remaining cancer and is refusing adjuvant endocrine therapy? ...

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