Wiki Active vs Hx of Cancer_Treatment discontinued

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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
 
The ICD10 guidelines state that personal history is only to be used when a primary malignancy has been previously excised or eradicated from its site, there is no further treatment, and there is no evidence of any existing primary malignancy at that site.
 
I agree, it is still active. But if the patient is not receiving treatment, what is it that you need a code for?

I would only code it if it's related to the visit or considered when treating the patient for something else (i.e. can he have this medication for a URI with the type of cancer he has), or during PEs just because it's an active problem.
 
The ICD10 guidelines state that personal history is only to be used when a primary malignancy has been previously excised or eradicated from its site, there is no further treatment, and there is no evidence of any existing primary malignancy at that site.
I agree, it is still active. But if the patient is not receiving treatment, what is it that you need a code for?
Yes, there lies the confusion. Cancer is active, however, patient chooses to stop treatment. From a coding perspective what does that mean? And, if the patient elects to stop treatment is that decision/discussion with the patient required to be documented in order to support the code that correlates with this scenario?

Thank you.
 
I would only code it if it's related to the visit or considered when treating the patient for something else (i.e. can he have this medication for a URI with the type of cancer he has), or during PEs just because it's an active problem.
For this scenario it was the oncologist's note seeing the patient for the cancer with mets. Active vs Personal History codes reflect patient's health status and could potentially impact risk adjustment.

Thank you.
 
For this scenario it was the oncologist's note seeing the patient for the cancer with mets. Active vs Personal History codes reflect patient's health status and could potentially impact risk adjustment.

Thank you.
It's active and will always be active based on the ICD10 guideline I listed. You can read the full guidelines on neoplasms and they're pretty clear how to code.
 
Yes, there lies the confusion. Cancer is active, however, patient chooses to stop treatment. From a coding perspective what does that mean? And, if the patient elects to stop treatment is that decision/discussion with the patient required to be documented in order to support the code that correlates with this scenario?

Thank you.
Stopping treatment doesn't mean the disease is no longer active.

It doesn't change anything from a coding perspective - it's either relevant to the encounter or it's not. If the patient is seeing a provider (which would indicate to me that they are still receiving some kind of services, if not treatment for the cancer) then you would code accordingly. If the cancer has some bearing on the encounter, then you code the cancer - if it doesn't, then you don't. It would never be coded as history unless the provider documents that the patient doesn't have it any more.
 
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