Breast Cancer and Chemotherapy

Chief Complaint:

The patient is a 44 year old female with Estrogen positive, Stage II invasive ductal carcinoma in the lower inner quadrant of the left breast. She has been receiving chemotherapy and complains of extreme fatigue, headaches, dizziness and rapid heart rate. Hematology studies indicate aplastic anemia consistent with chemotherapy treatment.

History:

• Patient has completed first round of chemotherapy.

Assessment:

• Malignancy left breast; estrogen positive
• Drug induced aplastic anemia

Documentation Tips

ICD-10 includes a new guideline that requires the reporting of an adverse effect code when anemia is associated with chemotherapy.

Comparison of Current ICD-9 Code and Illustrative ICD-10 Codes