Wiki Coding patient with cancer seen for neck spasm

[sorcha48]

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.

 

[trarut]

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.

 

[sorcha48]

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.

 

[trarut]

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.

 

[sorcha48]

Thank you. I wanted to make sure I was not incorrect in the assignment of the code.