“History of” Begins When Active Treatment Ends

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  • July 18, 2014
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Question: When does a “history of cancer” diagnosis begin? For example, if a patient has been diagnosed with cancer, does a “history of” diagnosis start immediately, or after a predetermined time?
Answer: According to ICD-9-CM guidelines, “history of” means the condition no longer exists and no active treatment is being received (although the condition can reoccur). Therefore, when treatment directed at the cancer ends, and there is no further evidence of cancer remaining, you may report a “history of cancer” diagnosis.
Be aware that you should report a history of previous conditions using a V code (when reporting from ICD-9-CM) only if the historical condition affects patient care, or substantiates the need for a patient to seek medical attention. For example, if the individual has a personal history of malignant breast cancer, you would look up “History of” in the ICD-9-CM Index to Diseases (not “malignant neoplasm”). You would report V10.3 Personal history of malignant neoplasm of breast only if relevant to the current episode of care (for instance, the patient is in for a mammogram, or tests are being run to evaluate cancer suspected in another organ).

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

No Responses to ““History of” Begins When Active Treatment Ends”

  1. Jeanette L. Masek, MD says:

    In many clinic notes it is useful to include several significant diagnoses in the assessment even if that problem has not been directly addressed during the visit, as a way to keep the diagnosis in the forefront of the patient’s care. However, that does not mean it has to be counted through the E and M guidelines as part of the services delivered on that date. The clinic record serves as a guide to all involved in the health care team of what is important for that patient, not just as the minimum necessary documentation to reach a given level of reimbursement. In some EHR’s it may be possible to enter the problem without ICD code, so as not to be counted by the coder, but in mine it is faster to enter the code so it brings up the description.
    We do not consider a person cured of a cancer until 5 to 10 years after there is no evidence of disease, so that the usual time period for metastasis/recurrence to become visible has passed; after this we would tell a patient they are cured, rather than currently cancer free.
    I think I will start using this format:
    V10.X Hx of___________ cancer 2011, NED to date