How many problems would you give credit for?

Subjective: Pt reports no new signs or symptoms. She continues to smoke. She is also overweight. At this juncture we will attempt to coordinate our outpatient visits with Radiation Oncology and I have scheduled the patient to return in 6 months. A DEXA scan will be performed prior to that visit.

Assessment summary: 
 
1.  10/2015-Stage IIA(T2(2.2cm),N0,M0,G2) ER+,PR+,HER2-neg IDC right breast   CBC and differential 
  Comprehensive metabolic panel 
  The patient remains on Arimidex without significant sequelae. She has no signs or symptoms of recurrent disease 
   
2.  Postmenopausal   DEXA Bone Density Skeleton 
  We will check her DEXA scan and encouraged the patient to continue to take her calcium and vitamins. 
   
3.  Long term (current) use of aromatase inhibitors   DEXA Bone Density Skeleton 
  We will check her bone scan which was normal a year ago looking for any signs of accelerated osteoporosis 
  I once again implored the patient to discontinue her tobacco habit, probably to no avail 
 
 
 
Return in about 6 months (around 2/19/2017) for Physician visit, labs prior.


Would you count long term use of aromatase inhibitor as a separate problem or would you consider it the treatment for breast cancer?

We thought 2 stable problems: breast cancer & menopause?
Thanks

Comments

  • I wouldn't count aromatase as another problem (unless she's having side effects?) but does it have a Z code?  I'd include that along with the cancer Dx.
    If this is a Medicare patient, I might add a Dx code for "tobacco dependence" (I don't know the exact words they use in the book). Even though she's not being treated for it (Cessation), it still impacts her health, esp. in light of her cancer Dx.
    Brenda Hanrahan

  • I wouldn’t count it as a “problem”, but would include the dx of long term (current) use of aromatase Z79.811 due to the fact that “Aromatase inhibitors cause a loss of bone density, which leads to higher rates of osteoporosis and bone fractures” and supports the medical necessity for the DEXA scan.

    Mindy L Dowd CPC,CPMA
    Denver Arthritis Clinic
    200 Spruce St
    Suite 100
    Denver,CO 80230
    (303)302-7433
    mdowd@dacdenver.com

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