History of Breast Cancer
In my practice, whether the cancer changes from active or history, is usually driven by the physician. But, in saying that, I believe the Coding Guidelines state that as long as physician states 'no evidence of recurrence' and the patient has not been on any treatment for past 5 years, including drug therapy of any kind, then the code can be changed to 'history of'. We generally update code to history of once patient is 5 years out from any treatment and physician states no recurrence of disease.
If in doubt, I would definitely query the physician as to how he would like the disease to be represented by coding.
Barb Angell, CPC
Orlando, FL