Patient with breast cancer in active treatment with ARIMIDEX with complaints of weight gain and mild hot flashes related to the endocrine therapy. In the assessment and plan my provider documents: stage I stable disease, tolerating treatment satisfactorily. ANED, normal exam, doing well, interval 6 months. We had a long conversation regarding endocrine therapy and the importance of watching diet. Counseling was provided regarding strategies to reduce hot flashes related to endocrine therapy including changing the schedule the medications are taken on.

Would you code for the weight gain and hot flashes if you’re not managing the patient’s medication?

Here is what I have so far:

1) breast cancer code
2) endocrine therapy usages Z79.811

Thanks,
Overthinking it I’m Sure