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Bladder CA 188.9 versus hx of bladder CA V10.51

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I have a question regarding the use of 188.9 versus V10.51.

We see bladder CA patients routinely for surveillance cystoscopy, sometimes every 3 months for several years and then yearly, etc.

ICD-9 says that once the previous malignancy has been excised and there is no evidence of existing malignancy, you should go to using the hx code. However, the coding staff (who has been doing it for 20+ years in this office) says I should continue using the 188.9 code because the primary malignancy has not been "excised." It was treated in some form or fashion but not excised as such. It may no longer exist but technically the organ still remains.

My thought is that since the patient has been stated to have NED, it should now be a hx code that is being used for the surveillance cysto that is being done sometimes 15 years after the initial CA tx.

Help!
 

mitchellde

True Blue
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Columbia, MO
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The organ does not have to be removed for the cancer to be history. Once the malignancy is no longer being treated with active treatment and the provider documents NED, the cancer is coded as history of.
 
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Thank you for your response. That is what I thought.

You are always most helpful, and I do appreciate you :)
 
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