History of Coding

[karenhulka]

if a patient presents to the office as "Status Post Breast Cancer" and the medical record clearly states there is no new evidence of disease, should this be coded as a history of breast cancer or should a breast cancer diagnosis be used.

 

[consultingbykristin]

The coding guidelines indicate once the cancer is surgically eradicated and no further treatment is being directed at the malignancy whether it's chemo, radiation or medications such as Tamoxifen, Femara, etc...we are to code as personal history.

If the physician's notes do not indicate any information one way or the other, I advise to 'query' for clarification and when in doubt, code as personal history rather than active cancer.

 

[BAngell]

History of Breast Cancer

In my practice, whether the cancer changes from active or history, is usually driven by the physician. But, in saying that, I believe the Coding Guidelines state that as long as physician states 'no evidence of recurrence' and the patient has not been on any treatment for past 5 years, including drug therapy of any kind, then the code can be changed to 'history of'. We generally update code to history of once patient is 5 years out from any treatment and physician states no recurrence of disease.

If in doubt, I would definitely query the physician as to how he would like the disease to be represented by coding.

Barb Angell, CPC
Orlando, FL

 

[klw1988]

What do you code as the primary dx code? The history of malignant neoplasms codes and the follow up encounter codes can no be listed as primary dx codes. This has been a big problem in my practice because the doctors are seeing patients with NED and no active treatment but still coding the original neoplasm code.

 

[mitchellde]

What do you code as the primary dx code? The history of malignant neoplasms codes and the follow up encounter codes can no be listed as primary dx codes. This has been a big problem in my practice because the doctors are seeing patients with NED and no active treatment but still coding the original neoplasm code.

This is not true. The history of neoplasm codes as well as the follow-up V codes are allowed as first-listed codes.

 

[klw1988]

Thank you so much. I'm getting a lot of argument that this will not get paid. We will give it a shot.