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just another coder said:
I was just reading in the dx thread about when to use h/o. The example was breast cancer.

https://www.aapc.com/memberarea/forums/showthread.php?t=71887

So what about when the Clinical Data says Breast Cancer but elswhere it says no residual cancer? Some of the CPTs for Surgical Pathology are for with or without neoplasm.
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You use the reason for the encounter, that day. Use the surgical path report to determine whether there is an active cancer or not - it's the most definitive. If the cancer has been completely eradicated, and the patient has healed from the treatment, you can use a follow-up code for follow-up visits pertaining directly to the previous cancer, or a personal history code for informational purposes, when the patient is being seen for something else (eg, not the cancer). The personal Hx codes are not to be used as a primary diagnosis (ever...they're "FYI" codes only). It really sounds more like you need to be considering an aftercare or follow up code, though - 'history of' codes are just that - history. They're not for use when the patient has an active problem, or is being treated following surgery on the problem, and they're not used to describe encounters where the patient is receiving a follow-up exam, pertaining to that illness. Make sense?
 
Thanks Brandi, I didn't have an actual chart in fornt of me then but now I do. Here's my example:

Diagnosis:

A. New superior margin, uqo right breast:
Negative for invasive carcinoma or duct carcinoma in situ

B. New inferior margin, uqo right breast:
Negative for invasive carcinoma or duct carcinoma in situ

C. New medial aspect of superior margin, uqo right breast:
Negative for invasive carcinoma or duct carcinoma in situ

Pre-Op diagnosis:

Right breast cancer

Post-Op diagnosis:

Same

So, you see they say negative but then they say right breast cancer. Now in this case the synoptic report does say infiltrating cancer under tumor type but sometimes it does not. Sigh, just sayin' :p
 
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