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v1.0.0
ICD-10 Guide
DiagnosesHistory Of Mastectomy

History Of Mastectomy

ICD-10 Coding for History of Mastectomy(Z85.3, Z90.1-)

PRIMARY SPECIALTYOncology
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is History Of Mastectomy?
Essential facts and insights about History of Mastectomy

Key Clinical Considerations:

  • History of breast cancer diagnosis
  • Previous surgical intervention for breast cancer
  • Potential complications or sequelae from mastectomy

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient's surgical history including date and type of mastectomy
  • Oncologist's assessment of cancer status post-mastectomy
  • Follow-up care and any ongoing treatment plans

Coding Guidelines

Usage Guidelines & Examples

  • Ensure correct use of Z codes for history of mastectomy versus active treatment codes.
  • Common errors include misclassifying the type of mastectomy or failing to document follow-up care.

Code Exclusions

Important Exclusions

  • Active breast cancer diagnoses
  • Codes for reconstructive surgery following mastectomy

Related ICD-10 Codes

Primary Codes
Z85.3
Personal history of malignant neoplasm of breast
Ancillary Codes
Z08
Z85.3
for surveillance visits.
Differential Codes
C50.-
C50
.- if the patient is still undergoing active treatment.

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Oncology

Specialty Applications

  • Patients with a history of breast cancer and mastectomy
  • Oncology clinics and surgical centers

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

What are the documentation requirements?

Document the type of mastectomy, date of procedure, and any subsequent treatments.

What are the billing considerations?

Ensure accurate coding of history and any related follow-up care to avoid claim denials.