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Active vs history of cancer during postop period

J

jenniejolamb

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Warren, OR
Patient had lobe excised 12/27/18. Saw the Pulmonologist 2/19 who referred patient to Oncology for adjuvant chemotherapy but stated not sure patient was a candidate due to comorbidities. Saw Oncologist 3/19 and he documented cancer was excised and because of the type of cancer no need for adjuvant chemotherapy. Question: Can the February note be coded as active disease? Since the patient is still in the postop period? Any source would be appreciated. Thank you!
 
This is a good question. Since the patient is still being technically treated, meaning the provider was sending them for a referral for chemo even though the cancer was excised, you could consider as active. The oncologist needed to see the patient to assess whether chemo was a good option due to the patient's comorbidities.

Nikki Taylor, MSHCI, COC, CPC, CPMA, CRC
Sr. Development Editor, AAPC
 
I agree, if the provider was still considering chemotherapy directed at the cancer at the time of the encounter and had not yet made the determination that the excised lesion no longer required treatment, then it can still be coded as an active condition.
 
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