Wiki Coding patient with cancer seen for neck spasm

sorcha48

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The patient has a history of right tonsil cancer. Treatment is over.
Seen by the Otolaryngoloist for neck spasm.
Coder had C09.9 has the principle diagnosis code.
I think it should be M62.838.
Any advice.
 
DId the otolaryngologist diagnose a recurrence of the tonsil cancer? If not, I would code the neck spasm (assuming no underlying cause that should be coded instead) and history of tonsil cancer.
 
No diagnosis of a recurrence. Dr. referred to it as a history of. I thought it would be the neck spasm as that was the reason he was being seen.
 
Then I'd definitely go with the neck spasm. The cancer history is relevant because prior surgery could be a contributing factor to the neck spasm but this is not a case where the cancer would be coded primary based on what you've stated.
 
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