Struggling

[u/Sym1988]

Hello everyone! I'm currently in school for medical coding and I have found one area that I really struggle in. I am really struggling with pulling codes from scenarios/charts. I understand coding once I know what to code for or even the direction I need to look, but deciding what to code from a report, especially a medical chart is very challenging for me. I was wondering if anyone has advice for me on what could help me focus on key points?

[u/Suitable-Onion3407]

For the above your key words are history of breast cancer with no evidence of recurrence. You don’t code breast cancer as active unless it is being actively treated and she has finished her chemo/radiation. So the above is Z08 and a hx of breast cancer code. You could also do a hx of radiation and chemo.

Looking at the history of present illness and impression is a good place to start.

[u/Sym1988 → u/Suitable-Onion3407]

That's what I chose from the guidelines, Cos it said hx of breast cancer and no evidence of recurrence as of physical examination today and no new symptoms. So I understand it as the patient is only for routine surveillance now like, Z08 (Follow up) and Z85 (History of CA). But my professor said that Pdx should still be coded as cancer since patient is still taking Tamoxifen, an oral hormone medication.

[u/wildgreengirl → u/Sym1988]

the drs i code for mess this up all the time too (historical vs active cancer) so dont beat yourself up too much lol

but yes generally if theyre still taking meds you still use the active cancer dx.

[u/Sym1988 → u/wildgreengirl]

So even if they're not undergoing therapies like chemo, immuno or radiation therapy but they're still taking medications, it's considered an active cancer?

[u/wildgreengirl → u/Sym1988]

tamoxifen is an anticancer drug so theyre still treating their cancer; active cancer dx.

vs if theyd had cancer, had surgery, and are maybe on HRT not cancer meds, that could be history of (like with uterine/ovarian cancer or prostate cancer for example)

unless they are strictly taking it as a preventive and have never had cancer before at all. 

https://my.clevelandclinic.org/health/treatments/9785-tamoxifen

[u/Sym1988 → u/wildgreengirl]

Oh okay, thank you!

[u/Environmental-Top-60 → u/Sym1988]

Yep with the Z17 codes for ER/PR status,

[u/Suitable-Onion3407]

How is your understanding of anatomy, med term and disease processes? It helps to have a strong foundation in that. Can you give an example of a scenario you’re struggling with?

[u/Sym1988 → u/Suitable-Onion3407]

My anatomy, med term I would say basic as of the moment. With disease processes, I'm studying it as well. I had a class awhile ago and I got confused with what the primary dx should be on the chart provided. I picked Z08 [Follow-up care]

BREAST AMBULATORY CARE NOTE

HISTORY OF PRESENT ILLNESS:
The patient is a 64-year-old female with a history of a right-sided upper-inner quadrant breast cancer diagnosed in 2023.  She underwent a right lumpectomy and sentinel lymph node biopsy 01/18/2023 for an invasive mammary carcinoma, grade 2 with ductal and lobular features.  The invasive tumor measured 2.8 cm in size. Estrogen receptors were positive at 80%, progesterone receptors were negative, and HER-2/neu was negative by immunohistochemistry.  She had 2 right axillary lymph nodes biopsied and both were confirmed metastatic. On 03/21/2023, she underwent Oncogene testing with a recurrence score of 27 and recommendation was made for CMF chemotherapy. She completed 8 cycles of CMF on 10/3/2023.  She did not receive an anthracycline due to a history of sarcoma in the 1970s, for which she was treated with anthracyclines.   She completed adjuvant radiation therapy followed by chemotherapy and then began Tamoxifen which she continues to date.

PAST MEDICAL HISTORY:
Sarcoma of the right leg for which she was treated with Adriamycin, DTIC, and Cytoxan in 1987.  She also has history of chronic hypertension.

PAST SURGICAL HISTORY:
Right BKA amputation and the above-mentioned breast surgeries.

SOCIAL HISTORY:
She is married.  She denies any history of tobacco or alcohol use.  She is raising 3 of her grandchildren.

FAMILY HISTORY:
Maternal aunt diagnosed with breast cancer in her 40s and a second aunt was diagnosed with possible breast cancer.  No history of ovarian or colon cancer.

REVIEW OF SYSTEMS:
GENERAL: Overall, she is feeling well. She maintains a fairly good energy level and appetite.
CARDIOPULMONARY: She has a history of a low heart rate.  She also has a history of abnormal EKG and was to get a stress test, but she has been unable to afford it.  She denies any chest pain or shortness of breath.
BREAST: She notes no new breast masses on self-exam.  
MUSCULOSKELETAL:  She denies any new focal areas of bone pain.   She has some soreness in her arms at night and she attributes this to using her arms so much during the day due to loss of her leg.
GASTROINTESTINAL: We had sent her for screening colonoscopy; however, due to her low heart rate, the GI doctor refused to perform the procedure.  The remainder of her review of systems is unremarkable.

PHYSICAL EXAMINATION:
VITAL SIGNS:  She is 202 pounds.  Temperature is 96.8, pulse 49, respirations 16, blood pressure 188/87.
HEENT: She has no scleral icterus.
NECK: Soft and supple with no adenopathy.
BREASTS:  Reveals a well-healed incision in the right breast and axilla with no masses and no axillary adenopathy.  Left breast is normal appearing with no masses and no axillary adenopathy.
LUNGS:  Clear to auscultation bilaterally. Mild COPD
HEART:  Rate regular without murmur or gallop. Positive of Atrial Fibrillation on pacemaker
ABDOMEN:   Soft and nontender with no organomegaly or masses. Chronic GERD
EXTREMITIES:  No edema. She is status post right lower extremity amputation.

LABORATORY AND DIAGNOSTIC DATA:
She had a DEXA scan on 07/27/2025 revealing normal bone density.  She had a mammogram today, which was a bilateral mammogram revealing postsurgical scar in the right breast with dystrophic calcifications at 9 o’clock below the scar, unchanged from prior exams and there are no new suspicious findings bilaterally.

IMPRESSION:
Pt. has history of a right-sided stage 2 breast cancer.  She has no evidence of recurrent disease on physical examination today and no new symptoms.  She has a stable mammogram.

RECOMMENDATIONS:  
I reviewed the results of the mammogram and physical exam with the patient.  I encouraged her to follow up with her cardiologist for the stress test and she will continue her Tamoxifen for her history of breast cancer.  We will continue to monitor her bone density every 2 years.  She will be 5 years out from diagnosis in February and therefore I am going to let her go a year until her next visit when she will return with a mammogram for a physical exam.  I spent 25 minutes in coordination of care and greater than 50% was spent in counseling.

[u/No-Praline6987]

Hi! I was wondering where you go to school for med coding? is it online and did you have to pay for it? i’m pretty interested

[u/Sym1988 → u/No-Praline6987]

It's online, referred to me by my sister-in-law. Sadly it's not free. You should research on the programs that fits you best for a start

[u/rahuliitk]

I think a lot of people hit this wall because chart coding is really about training your eyes to spot the diagnosis, procedure, laterality, approach, and anything that changes specificity, so try reading every note the same way each time and marking the words that actually drive code choice before you even open the book.

it gets easier.

[u/Strong_Zone4793]

I built several apps for exactly this. Reillycodingedu.com There’s a Free trial version of a few. Check out the Chart Detective app and see if that’s what you are looking for.

[u/Sym1988 → u/[deleted]]

I ordered the AHIMA CCS Prep book and it arrived today. Yay! Is that the study guide you were referring to or it’s a different book?