This 35 years old female patient has carcinoma of the upper-outer left breast. She had a lumpectomy performed and a sentinel lymph node biopsy of the axillary lymph node. The pathology report for the lymph node.
Diagnosis code with POA: I do not how to code de POA code and I really tried. can some help me with this?
procedure codes:19301,38500
POA mean present on admission- so it is a yes (y) or a no (no) after the code.
Wheich is 233.0-y
To code the POA (Present on Admission) indicator for the diagnosis of carcinoma of the upper-outer left breast, you need to determine if the carcinoma was present at the time of admission or if it developed during the patient's stay in the hospital. This information is typically documented by the physician in the medical record.
If the carcinoma was present at the time of admission, you would code it as "Y" for present on admission. If the carcinoma developed during the patient's stay, you would code it as "N" for not present on admission.
It is important to communicate with the healthcare provider or review the medical documentation to ensure accurate coding of the POA indicator.
As for the procedure codes, based on the information provided, the following codes can be assigned:
1. Lumpectomy - The code 19301 is typically used for a partial mastectomy, which includes the removal of a breast tumor or an area of the breast tissue.
2. Sentinel lymph node biopsy - The code 38500 is used for the needle biopsy or excision of the sentinel lymph node in the axilla. This procedure determines the presence or absence of cancer cells in the lymph node.
Please note that accurate coding requires a thorough review of the medical documentation and familiarity with the appropriate coding guidelines and conventions. It is always recommended to consult an experienced medical coder or refer to specific coding references for complete and accurate coding.