Wiki coding ca and history of ca

[jcrahan13]

If a progress note states pt has a hx of bladder ca Z85.51 and the pt is presenting for regular cystoscopies for surveillance of said ca, is the diag coded as personal hx of bladder ca or as actively having the ca C67.4?
See portion of note below

79-year-old female with a history of high-grade T1 bladder cancer. She completed induction BCG. Recent urine cytology showed atypia. Surveillance cystoscopy showed no obvious recurrence. Results reviewed and discussed. I did recommend sending out her urine for fluorescence in situ hybridization. We will call if the results are concerning. I also recommended maintenance BCG. Risks and benefits of maintenance BCG discussed. She is agreeable

 

[mrusso@communitymedgroup.org]

If a progress note states pt has a hx of bladder ca Z85.51 and the pt is presenting for regular cystoscopies for surveillance of said ca, is the diag coded as personal hx of bladder ca or as actively having the ca C67.4?
See portion of note below

79-year-old female with a history of high-grade T1 bladder cancer. She completed induction BCG. Recent urine cytology showed atypia. Surveillance cystoscopy showed no obvious recurrence. Results reviewed and discussed. I did recommend sending out her urine for fluorescence in situ hybridization. We will call if the results are concerning. I also recommended maintenance BCG. Risks and benefits of maintenance BCG discussed. She is agreeable

According to Optum it depends if the patient's malignancy has been eradicated or is currently being treated. A cystoscopy is for surveillance and not a form of treatment, surgery or medication to treat the malignancy. Most Medicare Advantage companies consider hormone treatment after a malignancy as still an active malignancy (Breast and Prostate Cancer). Consider use of Personal HX of Bladder Cancer as one of your choices for a diagnosis. Please see their attachment below.