Encounter for prophylactic removal of breast

This code signifies an encounter where a patient is undergoing a procedure to preventatively remove breast tissue. This is typically performed to reduce the risk of developing breast cancer in individuals identified as high-risk. The removal is prophylactic, meaning it's done before any malignancy is detected.

Apply this code when a patient presents for a prophylactic mastectomy or lumpectomy due to a significantly elevated risk of breast cancer, such as a strong family history or a positive genetic test (e.g., BRCA1/BRCA2 mutation). It is appropriate for the surgical encounter itself, as well as pre-operative evaluations and post-operative follow-ups specifically related to this preventive measure.

• Do not use this code if a malignancy has already been diagnosed; instead, code the malignancy.
• Always sequence this code as the primary diagnosis when the prophylactic removal is the reason for the encounter.
• Ensure supporting documentation clearly indicates the prophylactic nature of the procedure and the underlying risk factors.