Wiki oncology coding

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rross

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The physician documents the patient has metastatic liver lesions of unclear etiology. The patient has a history of pancreatic cancer in 2001, and believes this is a late recurrence. It was coded as 197.7 and 199.1. It failed the edit and is awaiting a diagnosis that meets med. nec. That was under one dr. I am open to any suggestions of what I may have missed, or how I should code this in order to get paid if possible.


Under the new dr. coming in, he coded it as 157.9-which meets med. nec for the gemzar. So, everything since the new dr. came on has cleared the scrubber. I don't feel this is correct, because I have looked for new information stating without any doubt that this is pancreatic, considering it had been resected and with no definate recurrent mass at postsurgical site.

Thank you in advance for any assistance with this.
 
Sounds to me like your Dr. is treating the pt for the "recurrent" pancreatic cancer. If this is so, then it is 157.9. Gemzar (J9201) is not for the treatment of liver cancer, unless the cancer is in the intrahepatic bile ducts (155.1) as a primary site. As I'm sure you know, a patient can have more than one "primary" site. I would quiry both Drs. I hope this helps.
 
If the first dr. hadn't used words such as possibly, suspicious, most likely; I wouldn't have a problem using the 157.9. If the documentation was called into question would it stand up with those words? The path report had stated unknown primary that is why he chose the 199.1. Those are the claims that have failed the edit, 8 claims actually. So, because the patient has a history of pancreatic cancer that long ago, can I use the 157.9? I was thinking it would need to be a v-code which is not covered.
 
The fact he said he believes this to be a late recurrance and is treating the pt with Gemzar would be telling me that the pt has "active" pancreatic cancer. Has the pt always been your patient? I would look at his chart and see if perhaps he was taking an oral chemo drug and it just finally quit working against the cancer. I would ask the 1st Dr. to be a little clearer in his documentation about his "recurrence" DX.
 
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