Active or History? Follow-up oncology visit with no further treatment


Martinez, CA
Best answers
We are having a heated debate here on this subject. Here is the scenario:

Patient has cancer, let's just say colon cancer. Goes in for hemicolectomy. Surgery goes well, margins are clear, NED. Up to this point we are coding for the colon cancer.

Patient goes for his first follow-up visit with oncology. The oncologist decides that there will be no further treatment. How do you code this visit? Active or History of?

Some feel (myself included) that since the cancer has been excised and there is no evidence of disease, this visit should be treated as History of.

Others feel that since the purpose of this visit was to plan treatment, it should still be coded as active cancer. After this visit, however, it should be coded as History of. This leads us to a problem-- the oncologist never sees the patient again and never changes the diagnosis in the patient's problem list. It might remain there for years in error.

I'd like to hear your thoughts on this.