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Case Study Report Example
Rick Said:
ICD-9-CM questions?We Answered:
The thing of major significance in this note is that the woman has just been diagnosed with breast cancer. This appt was purely to discuss results and get her referred for treatment.Some people would throw in 'anxiety' as a diagnosis also, but there is nothing in the note to indicate anything out of the ordinary anxiety-wise. It is not pathological to be anxious in this situation.
I'd go with 174.9 (cancer, breast, female, uspecified) as the primary diagnosis. You don't have enough information to get any more detailed than that.
You might throw in 783.21 (abnormal decrease in weight) since it is mentioned, but the notes do not indicate any additional evaluation, counseling or treatment for it.