Kbarrett01
New
Looking for feedback on coding cancer as active or personal history.
Patient undergoing treatment for upper rectum cancer. PET Scan reveals metastasis to the liver. Patient decides to stop all cancer treatment. Is primary and secondary diagnoses coded as Active regardless of receiving treatment? I've heard conflicting feedback as to what constitutes coding Active vs Personal History. Such as active cancer and no documentation showing the treatment is considered Personal Hx, however, if active cancer AND documentation as to why there is no treatment (patient's end of life choice, etc.) then it can be coded as Active. Looking for any supporting documentation and/or guidelines on how to address this type of scenario.
Thank you!
Kammi
Patient undergoing treatment for upper rectum cancer. PET Scan reveals metastasis to the liver. Patient decides to stop all cancer treatment. Is primary and secondary diagnoses coded as Active regardless of receiving treatment? I've heard conflicting feedback as to what constitutes coding Active vs Personal History. Such as active cancer and no documentation showing the treatment is considered Personal Hx, however, if active cancer AND documentation as to why there is no treatment (patient's end of life choice, etc.) then it can be coded as Active. Looking for any supporting documentation and/or guidelines on how to address this type of scenario.
Thank you!
Kammi