ICD-9 Clarification

ldm3405

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I need clarification regarding "history" codes. I am strictly using diagnostic codes. If a physician states "patient with hx of Afib, currently on coumadin, but presently in sinus rhythm, would Afib still be coded? I interpret it as the coumadin being a "preventative measure" and at this point the Afib should not be reported. How should this be interpreted? Also, for patients with cancer, ie breast cancer, that have went through chemo and radiation and masectomy and show no signs of the disease but are on the Tamoxifen for 5 years, do you still code the breast cancer? I interpret that the cancer is gone and there are preventative measures in place.....so actually, the patients no longer has the cancer. What is the correct way to handle coding with these situations?

Thanks!
 

myeo

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Hi,
It is my understanding that if the patient is still being treated for the condition, i.e. Coumadin for the Afib and Tamoxafin for the Breast CA, the doctor can document as a current condition being treated. It effects the physician's medical decision making, but he/she must address this in his documentation.
 

Happycoding

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Hi,
You can code breast cancer (174.9) unless the physician documents history of breat cancer.for history of A.fib you can code A.fib even he is in treatment.
 

Lisa Bledsoe

True Blue
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If the patient is currently being treated for the cancer (ie tamoxafin) then you code the cancer code. I think the same scenario applies for coumadin and afib...code 427.31 and V58.61.
 
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