Coding of Cancer - ICD 10 guidelines for coding H/O or Active

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It becomes very confusing on coding Breast Cancer or Prostrate Cancer when still on medications, but no indication of disease. Please see example below. Patient was seen by physician on 10/15/2015.

ONC HX: Multicentric right breast cancer T2N1M0. Date of diagnosis 11/20/2008. ER 95%, PR 87%, HER2/neu negative by FISH. Tumor size 3.2 cm. Right mastectomy with axillary sentinel biopsy 01/21/2009 by Dr. Adjuvant chemotherapy with AC x4 cycles followed by Taxol q. week x12 cycles 02/24/2009 to 08/04/2009, Arimidex 1 mg p.o. daily date of start is 09/2009.

IMPRESSION: Stage II breast cancer, ER/PR positive, currently on Arimidex. Excellent tolerance
Continue Arimidex 1 mg p.o. daily

Would this be coded as history of breast cancer or as active breast cancer?

Barbara
 
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CodingKing

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If its being administered to prevent recurrence vs treating active cancer doesn't that make it prophylactic treatment? The cancer has already been removed and chemo is completed. I thought that makes it history of?
 

mitchellde

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It is being give to suppress the activation if you will of cancer cells. The cancer cells are still there they are just not very active. It still treats the breast cancer so you code the cancer active.
 
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