Personal History of Cancer ICD-10-CM codes

Category Z85 applies when a primary malignancy has been excised or eradicated, no treatment is directed at that site, and there is no evidence of remaining disease (section I.C.2.d). Codes are by site: Z85.03x and Z85.04x for colon and rectum, Z85.118 for lung, Z85.3 for breast, Z85.41 for cervix, Z85.43 for ovary, Z85.46 for prostate, Z85.51 for bladder, Z85.528 for kidney, Z85.6 for leukemia, Z85.71 and Z85.72 for Hodgkin and non-Hodgkin lymphoma, Z85.820 for melanoma, Z85.828 for other skin cancer, Z85.850 for thyroid. Z85.9 (unspecified site) should only be used when the record does not name the site.

The line between active cancer and history is treatment, not time. A patient who finished chemotherapy and surgery two years ago with no evidence of disease is Z85; a patient with the same history who is still on tamoxifen, an aromatase inhibitor, androgen deprivation, or maintenance immunotherapy is still under treatment and keeps the active C code (with the matching Z79.81x or Z79.6x drug code). A patient with metastatic disease keeps the C7x secondary site code even when the primary was removed, and the removed primary gets Z85 only if the provider documents it as eradicated. Documentation that says only history of breast cancer with no treatment detail should prompt a query.

Z85 codes are secondary except when paired with Z08 for the surveillance visit itself, where Z08 is first-listed and Z85 follows. On a screening claim the history code explains the higher risk: Z12.31 with Z85.3 for a surveillance mammogram, Z12.11 or Z08 with Z85.038 for a surveillance colonoscopy. Z85 also belongs on any encounter where the history affects care, such as pre-op clearance or a new symptom that could represent recurrence.

Z85 is for primary malignancies only. History of a treated in-situ neoplasm is Z86.00x (Z86.000 breast, Z86.001 cervix), history of a benign neoplasm is Z86.01x, and the treatment history codes Z92.21 (chemotherapy) and Z92.3 (radiation) can be added to document what was done. Prophylactic surgery in a survivor or a carrier is Z40.0x with the Z85 or Z15 code as the reason.