ICD-9-CM questions?

I have gotten the hang of going and looking individual things up but i get confused with case studies. Example:
Physicaian office note
4/25/ weight: 154lb decrease from 2 weeks ago
chief Complaint: loss of weight, here for follow- up from breast biopsy.
Sally was seen 2 weeks ago & and i palpated a mass in her left breast. She was sent for biopsy. she is here for follow-up.
Breast: mass present in left breast
Abdomen: normal, no mass or tenderness
patient is anxious about results
pathologyu report reviewed w/ patient that confirmed cancer of breast. patient refered to oncology

ICD-9-CM Code assignment________________ and why....

(im confused on what to code out of the case study whats important and whats not?)

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.

ICD-9-CM stands for International Classification of Diseases (ICD), Ninth Revision (9th), Clinical Modification (CM). It is the "official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States." It's one way to tract diseases such as cancer.

http://www.cdc.gov/nchs/about/otheract/i...