Pancreatic cancer or metestatic pancreatic cancer

millortsui

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Physician wrote notes stating under HPI that patient had metastic pancreatic cancer. Then under the assessment, physician just wrote pancreatic cancer. So which one should I go by?

Under the condition:
1. no way I can ask the physician.
2. physician was the patient's PCP not his oncologist.
3. both notes (HPI or Assessment) stated that patient was to follow up with oncologist.

Please advise.
 

terribrown

Networker
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When you can't query the provider, I would suggest you be conservative. If no where in the note does the physician describe where else the cancer is, and whether the pancreas is primary or secondary...yet clearly is addressing their physical status while suffering from this disease, I would suggest you code it as primary. HPI is subjective (may be coming from the patient) but the assessment is what the provider is actually stating it is.
 
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