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Wiki Would we code active cancer or history of cancer

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richlr

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Would we code active cancer "C50.512" for the below visit note? or is it "history of" Official Coding Guidelines says if cancer is documented as excised, eradicated and is on current treatment, it is active. But since Tamoxifen can be used to treat active cancer and can be used for historical cancer, I wonder if this is used to prevent recurrence.

XAMPLE: H/O BREAST CANCER VS. CURRENT CANCER

Subjective - 68-year old female came to the office today complaining of increased pain in her left knee. She states “I cannot sleep at night because the pain in my knee is so bad.” She also states that she can no longer do house work and other activities that she used to enjoy. She is currently on Tamoxifen for history of Lt. Breast Cancer. She is now one year S/P Lt. Mastectomy, chemo and radiation therapy without evidence of recurrence. See below= just send that

Ojective - Vital Signs – BP: 130/78, Weight. 210 lbs., Oxygen Sat: 97%; Pulse: 75; Temp: 98.3

Physical Exam:General – Obese; Skin, Eyes, Ears, Nose, Throat, Neck, Lungs, Heart, Abdomen,Neuro. – Within Normal Limits, Extremities: Pain and crepitus on flexion/extension left knee

Assessment and plan

Degenerative Joint Disease left knee

Lt/ Breast Cancer

S/P Mastectomy

Plan: Orthopedic consult for possible knee injections

LABS: FBG-92, HgbAIc – 6

Medication List: Advil, Tamoxifen, Ambien

PMH – Past history of Degenerative Joint Disease, Mastectomy 1 yr. ago for Breast Cancer, followed by radiation and chemotherapy for positive lymph nodes; currently taking Tamoxifen. Her last exam, 6 months ago, showed no recurrence

Physician Signature: Electronically Signed by: ___________ 12/04/2016

ICD-10-CM codes
 
richlr said:
Would we code active cancer "C50.512" for the below visit note? or is it "history of" Official Coding Guidelines says if cancer is documented as excised, eradicated and is on current treatment, it is active. But since Tamoxifen can be used to treat active cancer and can be used for historical cancer, I wonder if this is used to prevent recurrence.

XAMPLE: H/O BREAST CANCER VS. CURRENT CANCER

Subjective - 68-year old female came to the office today complaining of increased pain in her left knee. She states “I cannot sleep at night because the pain in my knee is so bad.” She also states that she can no longer do house work and other activities that she used to enjoy. She is currently on Tamoxifen for history of Lt. Breast Cancer. She is now one year S/P Lt. Mastectomy, chemo and radiation therapy without evidence of recurrence. See below= just send that

Ojective - Vital Signs – BP: 130/78, Weight. 210 lbs., Oxygen Sat: 97%; Pulse: 75; Temp: 98.3

Physical Exam:General – Obese; Skin, Eyes, Ears, Nose, Throat, Neck, Lungs, Heart, Abdomen,Neuro. – Within Normal Limits, Extremities: Pain and crepitus on flexion/extension left knee

Assessment and plan

Degenerative Joint Disease left knee

Lt/ Breast Cancer

S/P Mastectomy

Plan: Orthopedic consult for possible knee injections

LABS: FBG-92, HgbAIc – 6

Medication List: Advil, Tamoxifen, Ambien

PMH – Past history of Degenerative Joint Disease, Mastectomy 1 yr. ago for Breast Cancer, followed by radiation and chemotherapy for positive lymph nodes; currently taking Tamoxifen. Her last exam, 6 months ago, showed no recurrence

Physician Signature: Electronically Signed by: ___________ 12/04/2016

ICD-10-CM codes
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Tamoxifen can be prescribed either as treatment for active breast cancer or as prophylactically to prevent recurrence. Patients can take it as a prophylaxis for many years. Since I work in oncology, if the documentation for a patient's follow up care isn't clear on why the Tamoxifen was prescribed I can ask the physician.

In this case, I would not code active breast cancer based on this note. The patient had a mastectomy a year ago and has completed her course of chemo/radiation. This is an orthopedic consult for possible knee injections, so this doctor isn't managing anything breast cancer related.

There's nothing in this note that tells me the patient has active cancer, and even if queried the orthopedic physician would likely not have more specific information about the nature of the patient's Tamoxifen prescription.
 
Susan, I agree with you on that Orthopedic note, especially if it is the first time the Orthopedic provider is seeing that patient. Even though he said "currently treated with Tamoxifen." If the patient was long term established patient, then I would query the provider because he said currently treated and then brought it in A&P and since there was cancer in lymph nodes also, the provider should have said for prophylaxis. But some would code this active cancer due to Official Guidelines.
 
I would code to personal history of. The note only indicates "currently taking Tamoxifen" and "currently on Tamoxifen." I don't see the word treated.
Provider states no recurrence and history of.
Not enough support to code as active cancer.
 
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