“History of” Begins When Active Treatment Ends
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).