Wiki History of Cancer with Active Cancer?

[vdendywork@gmail.com]

Coding a history of breast cancer when the patient has active breast cancer? Two different orders for same patient have the RFV as "personal history of breast cancer" and "malignant neoplasm of breast". "Personal history of breast cancer" was used for a screening mammogram Z12.31, and the active cancer code for another diagnostic test. I wanted to ask the provider if the patient had cancer or a history of it, since you can't have both at the same time. Apparently the RFV "malignant neoplasm of breast" is correct, and the "personal history of breast cancer" is also correct - and you can use both of these on the same encounter.

This doesn't make sense in my mind, because I was taught that for it to be a history code, it cannot be an active disease. You either have cancer, or you have a history of cancer.

 

[LaurieEaston]

I believe the answer is contingent upon the documentation, and whether you’re coding for an outpatient encounter or diagnostic service. Same day encounter(s), same site?

I’ve located the guidelines for this topic.

Official guidelines I.C.2.d
Primary malignancy previously excised
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed diagnosis with the Z85 code used as a secondary code.

See also I.C.2.m
m. Current malignancy versus personal history of malignancy
When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.
When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.
Codes from subcategories Z85.0 – Z85.85 should only be assigned for the former site of a primary malignancy, not the site of a secondary malignancy. Code Z85.89 may be assigned for the former site(s) of either a primary or secondary malignancy.

Link to CMS ICD 10 Official Guidelines =

https://www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines.pdf

Hope this helps!
Laurie