History of cancer guidelines

[lillianivy]

I know the coding guidelines state that a pt is considered History of Cancer once they are no longer receiving treatment and there is no evidence of disease. A pt with colon cancer will keep their port in for 2 years after treatment is completed in case there is a recurrence. To a physician the pt is not considered History of until at least 5-10 years out with no recurrence. So this is where the coding and the clinical world clashes. Do we code by what the doctor wants? Not History of until they say? Or do we code strictly by our guidelines and make it history of since the scans show no evidence of disease and pt no longer receiving treatment. The problem is that with the EMR system we use it pulls the codes with description on the pt's office note and the doctors do not like seeing the History of on it, because they feel the pt is not considered history of. Plus they are worried if this would affect the way they treat them because they are to follow certain guidelines about how often they see the pt and have them retested. I need clarification and others insight on this.

Thank you,
Lydia

 

[Rachel.Kinsey@mercy.net]

Even though the scans might show no evidence of disease, they arent a dx. If the physician does not consider the patient to be disease-free and continues to document the disease as current, then I would code the disease as current. If the patient has the port in, then that port has to be checked, flushed, and replaced if issues arise, so they are still under surveillance/care/treatment in sequeala of that disease. Just as if a patient wasnt taking chemo/rad treatment but still had a rx for maintenance; they woudnt be taking the maintenance or wearing the port if the disease was not still in some way being treated, and thus, current. I would also consider this: the physician might not like seeing "hx of" in the patient's chart because if the patient sees that chart, sees the "hx of", they might think they are "cured" and behave differently or AMA, especially if the physician is telling the patient the disease is still current.