Wiki current cancer vs history cancer coding

[teemarie]

Can I get an opinion with respect to HCC coding and documentation? Provider assigned the current primary bladder cancer ICD-9, and he didn't assign the mets ICD-9 code. What is the appropriate way to code the scenario below?

“patient has urinary bladder cancer, with metastic lesions. Followed by Oncology”

 

[mitchellde]

if you do not know where the mets is you code 199.1 for unknow with the primary bladder code. 199.1 is used for either unknown primary or unknown secondary.

 

[Karolina]

As for the question if it is active Ca or history of depends on the current treatment. If there is active treatment (e.g. chemo, radiation, oral meds), then you have an active diag. If all active treatment has been completed and the patient is seen in regular intervals to make sure there is no cancer, than you would use history of.

 

[mjb5019]

metastasis

It is worth it to ask the provider if he knows the site of metastasis because that code has significantly more HCC value the the unspecified code.

If he doesn't know then you need to use the unspecified code.

I am always amazed at what providers sometimes know but didn't write down.