Wiki Coding for malignancies- active and historical

[warrenfamily103@gmail.com]

Hello,

I am hoping to get some clarification on a coding scenario I recently came across. The documentation states cancer with active treatment of prostate and also personal history of prostate cancer treated with Lupron by the VA in 2017. When I queried the provider to see if it is active or historical, she stated that it's both. Can these two codes be coded together? I didn't see any guideline against it in the code book. I appreciate any thoughts.

 

[csperoni]

If patient has a recurrence to the same site, I would only code the active malignancy. In the guidelines, it states to use history if "there is no evidence of any existing primary malignancy at that site." I interpret your situation as there is evidence of primary malignancy of the prostate, so history code would not be used.
Primary malignancy previously excised
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code.

 

[warrenfamily103@gmail.com]

If patient has a recurrence to the same site, I would only code the active malignancy. In the guidelines, it states to use history if "there is no evidence of any existing primary malignancy at that site." I interpret your situation as there is evidence of primary malignancy of the prostate, so history code would not be used.
Primary malignancy previously excised
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code.

Thank you, that was my first instinct, but the provider stated to code both and she did not amend the note. As it stands, it’s very conflicting as to what she means since both history of and active are documented. She is not one who likes to be questioned so that makes it all the more challenging.

 

[csperoni]

How and who may add/delete/change an ICD10 from a provider really depends on the company policy. A coder (or anyone really) may change a code the provider selected as long as the appropriate words are in the medical record. If a provider writes "DM II diet controlled without complications" but selects E09.1 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma, it may be corrected to E11.9 by anyone with appropriate knowledge depending on your internal company policy. My personal opinion is that any certified coder should be able to correct codes without even querying the provider (assuming the documentation reflects the new code), regardless of what code the provider selected from the top of a list after typing a word or two into the EMR. There are some companies that require the clinician to change the code.
My company does not require the clinician to change the code, and if the records reflected an active prostate malignancy and a history of prostate malignancy, I would code only the active without need to question the doctor. The clinician's responsibility is to care for the patient and document. The coder's responsibility is to take the words of the documentation and assign the appropriate codes.
If your company does require only the clinician to code, I would carefully query the clinician advising of the coding guidelines, ensuring it is clear I am not questioning clinical decisions, only advising on coding guidelines that 99.5% of clinicians are not trained about.
Good luck!