In simple words: This code is used when someone has surgery to remove a breast to prevent breast cancer, even if they don't currently have the disease.

This ICD-10-CM code describes an encounter for the prophylactic removal of a breast to reduce the risk of developing breast cancer. It's used when a patient, with or without a current breast condition, undergoes surgery primarily to prevent future malignancy.

Example 1: A 35-year-old woman with a strong family history of breast cancer, including her mother and sister who were diagnosed before age 50, tests positive for a BRCA1 gene mutation and elects to undergo a prophylactic mastectomy. , A woman with atypical ductal hyperplasia, a high-risk breast lesion, chooses to have a prophylactic mastectomy to reduce her risk of breast cancer., A 60-year-old woman with a history of lobular carcinoma in situ in one breast opts for a contralateral prophylactic mastectomy of the other breast to minimize the risk of developing cancer in that breast as well.

Documentation for Z40.01 should clearly state the medical reason for prophylactic breast removal. It should include details of the patient's risk factors, such as family history, genetic testing results (e.g., BRCA1/2 mutations), presence of high-risk lesions (e.g., atypical hyperplasia, lobular carcinoma in situ), or previous history of breast cancer in the other breast. A detailed operative report describing the procedure is also essential.

** Genetic counseling is often part of the decision-making process for prophylactic mastectomy and should be documented if performed. If breast reconstruction is performed at the same time, appropriate procedure codes for the reconstruction should also be reported.