Respond to the below post by discussing what kind of documentation (i.e. lab reports, radiology, etc.) the coder should look for in the medical record and any additional insight into the disease itself (medications, atypical signs and symptoms, etc.) or alternate names and common manifestations. Hint: code the disease using the ICD-10-CM codebook and look for any instructional notes and inclusion terms
Topic: Breast cancer.
This is one of the most common malignancy diseases affecting us
today. Breast cancer forms in the cells of the breast and it is often
hard to give an exact reason as to why this develops. The most common
sign of breast cancer is a lump either in the underarm or in the
breast. Knowing when something is abnormal with your own body is the most
important protection and self breast exams are always recommended by physicians
to help with early detection. Other symptoms that may be
experienced are discomfort, bloody discharge from the nipple, changes in
the shape and texture of the breast, and redness or swollen lymph nodes.
When a lump is detected your physician may request you have an x-ray of the
area along with a biopsy of the lump to determine if it is cancerous or
Treatments are always determined by
the stage of the cancer and they include surgery, radiation therapy, medication
therapy such as chemotherapy, and care from specialist to make sure the cancer
is contained. Surgery could involve a mammaplasty, a lumpectomy, or
a mastectomy. Radiation therapy is used to destroy cancer cell and shrink
tumors while chemotherapy is used to kill cells that are multiplying quickly.
In order to code this condition properly, the coder must know at what stage the
cancer is at and what route of treatment the physician has decided to go
in. Once a plan has been set in place the coding process can begin.
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